GS 110-91 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: MELINDA LESCAR Operation Type: Center Case Number: 0326-130L Visit Date: 3/12/2026 Number Present: 13 Completed Date: 3/12/2026 Age: From 0 To 3 Total Minutes: 165 Time In: 01:30 PM Time Out: 04:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of childcare requirements. This visit was conducted with Nicole Gaines, Administrator. The allegations are as follows: There are concerns regarding Building/Fire code. During today’s visit, the allegations were discussed with you. You had the opportunity to respond. Information shared during this visit is documented in this visit summary. You also contacted Keeyama Williams-Mumford, owner, by telephone during the visit. Your program currently operates with a Four-Star license effective November 28, 2025. Restrictions include 1st shift daytime care; no cooking allowed in building; meets enhanced ratios. The NC Secretary of State website was reviewed on March 12, 2026, and The Leading Legacy Academy, LLC was listed as current and active. The program’s compliance history was 76% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • Adequate / Approved Space • License Posted • Permit Restrictions Allegation #1: There is a concern regarding Building/fire code compliance. Observation #1: During today’s visit, information was received by a collateral contact that facility’s fire alarm monitoring system has not been in working order since January 1, 2026. Ms. Gaines and Keeyama Williams-Mumford, owner, stated that the alarm system was repaired yesterday, and they are now using a new company for the monitoring system. Ms. Williams-Mumford stated the system was not working prior to yesterday due to issues with the previous alarm company. A representative from the Winston-Salem Fire Marshal’s Office was present during the visit and the fire alarm system was tested. All staff and children evacuated the building and the alarm was reset. The alarm system is in working order at this time. The Fire Marshal contacted the alarm monitoring system company and confirmed that the system was put into operation yesterday, March 11, 2026. Monthly fire drills were recorded, and the log was posted at the front entrance of the facility. Conclusion #1: Based on the above information and observations during today’s visit, there was enough information to support the allegation. This allegation was substantiated because the fire alarm monitoring system was not in working order at all times, which is required by fire code. This has been corrected with the repair of the alarm system on March 11, 2026. When the fire alarm was activated today, staff placed infants in a crib that did not have a reinforced bottom or larger wheels. The staff had difficulty getting the crib over a mat at the exit door and through the wet mulch, causing them to have to lift the crib and carry it. Three approved evacuations cribs are in the classroom but were not used. The following violations were cited during today’s visit: Violation Number Comment Rule 881 The evacuation crib or other approved device did not have wheels or a reinforced bottom. Five infants were not placed in an approved evacuation crib during a fire drill during today's visit. A crib without a reinforced bottom or larger wheels was used and could not be moved quickly over wet mulch. .0604(r) 899 The child care operator did not comply with all State laws, federal laws and/or local ordinances that pertain to child health, safety, and welfare, as required by General Statute 110-91. The fire alarm monitoring system for the facility has not been in working order since January 1, 2026. GS 110-91 Comments Section – 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. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before March 26, 2026. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to melinda.lescar@dhhs.nc.gov or mail two copies of the letter to: Melinda Lescar P.O. Box 25174 Winston Salem, NC 27114 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: We discussed with Ms. Gaines that during monthly fire drills you should ensure that the fire alarm monitoring system is in working order. You will determine this by calling the alarm system company to notify them of the fire drill. If at any time, the alarm system is not working you must immediately contact your fire inspector for guidance. Multiple staff members should be trained on how to conduct a fire drill using the fire alarm system to ensure that the drills are conducted if Ms. Gaines or Ms. Williams-Mumford are not present. The fire inspection report requires a record of employee training in fire prevention/evacuation and annual fire safety training on site. Your next fire inspection is due in April 2026. While one of the staff members caring for infant children stated that she realized during the evacuation that they were using the wrong crib, evacuation training as required for the fire inspection can help to ensure staff are using the proper cribs. Ms. Gaines stated that the training will be scheduled for next week by the local fire department. Submit a roster with staff names present for the training, with the date and time of the training, and a signature of the trainer, to Ms. Lescar with you violation compliance documentation. You must notify your consultant 30 days prior to changing the ownership status of your facility. Additional Information/Consultation: Please submit written approval by your Environmental Health Specialist if you are approved to use the stove in the kitchen and wish to prepare food on site. Currently there is a restriction on your license for no cooking. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Contact me at Melinda Lescar, Child Care Consultant, (336) 987-0960, melinda.lescar@dhhs.nc.gov or Pam Hauser, Supervisor, (336)317-5003, pamela.hauser@dhhs.nc.gov if you have questions. For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: MELINDA LESCAR Operation Type: Center Case Number: 0326-130L Visit Date: 3/12/2026 Number Present: 13 Completed Date: 3/12/2026 Age: From 0 To 3 Total Minutes: 165 Time In: 01:30 PM Time Out: 04:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of childcare requirements. This visit was conducted with Nicole Gaines, Administrator. The allegations are as follows: There are concerns regarding Building/Fire code. During today’s visit, the allegations were discussed with you. You had the opportunity to respond. Information shared during this visit is documented in this visit summary. You also contacted Keeyama Williams-Mumford, owner, by telephone during the visit. Your program currently operates with a Four-Star license effective November 28, 2025. Restrictions include 1st shift daytime care; no cooking allowed in building; meets enhanced ratios. The NC Secretary of State website was reviewed on March 12, 2026, and The Leading Legacy Academy, LLC was listed as current and active. The program’s compliance history was 76% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • Adequate / Approved Space • License Posted • Permit Restrictions Allegation #1: There is a concern regarding Building/fire code compliance. Observation #1: During today’s visit, information was received by a collateral contact that facility’s fire alarm monitoring system has not been in working order since January 1, 2026. Ms. Gaines and Keeyama Williams-Mumford, owner, stated that the alarm system was repaired yesterday, and they are now using a new company for the monitoring system. Ms. Williams-Mumford stated the system was not working prior to yesterday due to issues with the previous alarm company. A representative from the Winston-Salem Fire Marshal’s Office was present during the visit and the fire alarm system was tested. All staff and children evacuated the building and the alarm was reset. The alarm system is in working order at this time. The Fire Marshal contacted the alarm monitoring system company and confirmed that the system was put into operation yesterday, March 11, 2026. Monthly fire drills were recorded, and the log was posted at the front entrance of the facility. Conclusion #1: Based on the above information and observations during today’s visit, there was enough information to support the allegation. This allegation was substantiated because the fire alarm monitoring system was not in working order at all times, which is required by fire code. This has been corrected with the repair of the alarm system on March 11, 2026. When the fire alarm was activated today, staff placed infants in a crib that did not have a reinforced bottom or larger wheels. The staff had difficulty getting the crib over a mat at the exit door and through the wet mulch, causing them to have to lift the crib and carry it. Three approved evacuations cribs are in the classroom but were not used. The following violations were cited during today’s visit: Violation Number Comment Rule 881 The evacuation crib or other approved device did not have wheels or a reinforced bottom. Five infants were not placed in an approved evacuation crib during a fire drill during today's visit. A crib without a reinforced bottom or larger wheels was used and could not be moved quickly over wet mulch. .0604(r) 899 The child care operator did not comply with all State laws, federal laws and/or local ordinances that pertain to child health, safety, and welfare, as required by General Statute 110-91. The fire alarm monitoring system for the facility has not been in working order since January 1, 2026. GS 110-91 Comments Section – 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. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before March 26, 2026. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to melinda.lescar@dhhs.nc.gov or mail two copies of the letter to: Melinda Lescar P.O. Box 25174 Winston Salem, NC 27114 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: We discussed with Ms. Gaines that during monthly fire drills you should ensure that the fire alarm monitoring system is in working order. You will determine this by calling the alarm system company to notify them of the fire drill. If at any time, the alarm system is not working you must immediately contact your fire inspector for guidance. Multiple staff members should be trained on how to conduct a fire drill using the fire alarm system to ensure that the drills are conducted if Ms. Gaines or Ms. Williams-Mumford are not present. The fire inspection report requires a record of employee training in fire prevention/evacuation and annual fire safety training on site. Your next fire inspection is due in April 2026. While one of the staff members caring for infant children stated that she realized during the evacuation that they were using the wrong crib, evacuation training as required for the fire inspection can help to ensure staff are using the proper cribs. Ms. Gaines stated that the training will be scheduled for next week by the local fire department. Submit a roster with staff names present for the training, with the date and time of the training, and a signature of the trainer, to Ms. Lescar with you violation compliance documentation. You must notify your consultant 30 days prior to changing the ownership status of your facility. Additional Information/Consultation: Please submit written approval by your Environmental Health Specialist if you are approved to use the stove in the kitchen and wish to prepare food on site. Currently there is a restriction on your license for no cooking. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Contact me at Melinda Lescar, Child Care Consultant, (336) 987-0960, melinda.lescar@dhhs.nc.gov or Pam Hauser, Supervisor, (336)317-5003, pamela.hauser@dhhs.nc.gov if you have questions. For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.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: The Leading Legacy Academy Facility ID: 34001443 Consultant: MELINDA LESCAR Operation Type: Center Case Number: 1225-148L Visit Date: 12/18/2025 Number Present: 8 Completed Date: 12/18/2025 Age: From 0 To 1 Total Minutes: 140 Time In: 03:10 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of child care requirements. The allegations are as follows: There are concerns that the facility is not in compliance with laws and ordinances pertaining to the health, safety and welfare of children. I interviewed the administrator, and one staff member regarding the allegation(s). Based on the information provided, staff noticed spaces 1A and 1B were cold and the heat was not working December 15, 2025, and closed at noon. On December 16, 2025, children were in care in spaces 3 and 4, and space heaters were used and the facility closed early. On December 17, 2025, the facility was closed. During today’s visit, eight (8) children, infants and one year olds were observed in care in Spaces 3 and 4. Thermometers in the facility showed the temperature in the lobby was 71 degrees Fahrenheit, a space heater in the hallway read 66 degrees Fahrenheit, and there were not thermostats in space 3 or 4. The thermostat in space 1A and 1B was not working. Sanitation was contacted and it was advised to use a kitchen thermometer to measure the temperature in all the classrooms. One (1) space heater was in use in space 4 with one-year olds, and the temperature was 70 degrees Fahrenheit. In space 4 where infants were in care, the room temperature was 68 degrees Fahrenheit. In addition to the allegation, the following child care requirements were monitored: •Staff/child ratio- The facility meets enhanced ratios. During today’s visit, ratios were in compliance. •Supervision is in compliance. •Adequate/approved space - The space capacity for each classroom, observed staff/child ratios, and enrollment information provided by the facility were in compliance. •License posted and restrictions – The permit restrictions are first shift, meets enhanced ratios and no cooking allowed. During today’s visit, all restrictions were in compliance. Based upon the information received during interviews, space heaters were in use in two spaces where children were not present on December 16, 2025, due to issues with the heating system. Both North Carolina Fire and Building Codes prohibit the use of portable electric space heaters as an approved heating system in child care facilities. The allegation is substantiated. The following violations were observed/documented: Violation Number Comment Rule 899 The child care operator did not comply with all State laws, federal laws and/or local ordinances that pertain to child health, safety, and welfare, as required by General Statute 110-91. A space heater was in use in space 4, where one year old children were in care. A space heater was in use in the hallway outside space of 3 and 4. GS 110-91 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. On or before January 1, 2026, 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 that any information submitted by you is considered 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. Mail or email the information to: Melinda Lescar, Child Care Consultant PO Box 25174 Winston Salem, NC 27114 Melinda.lescar@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Technical Assistance: A violation (Item# 0899) was documented for failure to maintain compliance with all State laws, federal law and/or local ordinances that pertain to child health, safety, and welfare as required by North Carolina General Statute 110-1. In the event that the heating or cooling systems fail, and temperatures cannot be maintained between 65 and 85 degrees in the building as required by Sanitation Rule 15A NCAC 18A .2826, children cannot remain in care. You should immediately contact the building owner and a repair service provider to determine the timeframe for the repair, notify parents, contact you Environmental Health Specialist and building inspector, and contact your child care consultant to provide information on the issues, the requirement and timeframe for closure, and the steps you have taken to ensure repairs are made. In addition, you cannot make any modifications, such as space heaters, to provide heat or cooling without approval from a building inspector. Ms. Nicole Gaines, administrator stated during the visit that the facility temperature can be maintained between 65 to 85 degrees Fahrenheit without the use of space heaters on the left side of the building. Space heaters were removed from the facility during the visit. Issues within the building can occur that you cannot control such as loss of heat/air, electricity, water, and sewer issues. You can create a policy to follow in events such as these that will guide administrators and staff on the protocol to follow, the contacts to be made (including telephone numbers for agencies and individuals), and include a form for documentation. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Contact me at Melinda Lescar, Child Care Consultant (336) 987-0960, Melinda.lescar@dhhs.nc.gov or (Pam Hauser, Licensing Supervisor, (336) 317-5003, pamela.hauser@dhhs.nc.org) if you have questions. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: MELINDA LESCAR Operation Type: Center Case Number: 1225-148L Visit Date: 12/18/2025 Number Present: 8 Completed Date: 12/18/2025 Age: From 0 To 1 Total Minutes: 140 Time In: 03:10 PM Time Out: 05:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Complaint Visit Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of child care requirements. The allegations are as follows: There are concerns that the facility is not in compliance with laws and ordinances pertaining to the health, safety and welfare of children. I interviewed the administrator, and one staff member regarding the allegation(s). Based on the information provided, staff noticed spaces 1A and 1B were cold and the heat was not working December 15, 2025, and closed at noon. On December 16, 2025, children were in care in spaces 3 and 4, and space heaters were used and the facility closed early. On December 17, 2025, the facility was closed. During today’s visit, eight (8) children, infants and one year olds were observed in care in Spaces 3 and 4. Thermometers in the facility showed the temperature in the lobby was 71 degrees Fahrenheit, a space heater in the hallway read 66 degrees Fahrenheit, and there were not thermostats in space 3 or 4. The thermostat in space 1A and 1B was not working. Sanitation was contacted and it was advised to use a kitchen thermometer to measure the temperature in all the classrooms. One (1) space heater was in use in space 4 with one-year olds, and the temperature was 70 degrees Fahrenheit. In space 4 where infants were in care, the room temperature was 68 degrees Fahrenheit. In addition to the allegation, the following child care requirements were monitored: •Staff/child ratio- The facility meets enhanced ratios. During today’s visit, ratios were in compliance. •Supervision is in compliance. •Adequate/approved space - The space capacity for each classroom, observed staff/child ratios, and enrollment information provided by the facility were in compliance. •License posted and restrictions – The permit restrictions are first shift, meets enhanced ratios and no cooking allowed. During today’s visit, all restrictions were in compliance. Based upon the information received during interviews, space heaters were in use in two spaces where children were not present on December 16, 2025, due to issues with the heating system. Both North Carolina Fire and Building Codes prohibit the use of portable electric space heaters as an approved heating system in child care facilities. The allegation is substantiated. The following violations were observed/documented: Violation Number Comment Rule 899 The child care operator did not comply with all State laws, federal laws and/or local ordinances that pertain to child health, safety, and welfare, as required by General Statute 110-91. A space heater was in use in space 4, where one year old children were in care. A space heater was in use in the hallway outside space of 3 and 4. GS 110-91 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. On or before January 1, 2026, 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 that any information submitted by you is considered 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. Mail or email the information to: Melinda Lescar, Child Care Consultant PO Box 25174 Winston Salem, NC 27114 Melinda.lescar@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address registered with the DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Technical Assistance: A violation (Item# 0899) was documented for failure to maintain compliance with all State laws, federal law and/or local ordinances that pertain to child health, safety, and welfare as required by North Carolina General Statute 110-1. In the event that the heating or cooling systems fail, and temperatures cannot be maintained between 65 and 85 degrees in the building as required by Sanitation Rule 15A NCAC 18A .2826, children cannot remain in care. You should immediately contact the building owner and a repair service provider to determine the timeframe for the repair, notify parents, contact you Environmental Health Specialist and building inspector, and contact your child care consultant to provide information on the issues, the requirement and timeframe for closure, and the steps you have taken to ensure repairs are made. In addition, you cannot make any modifications, such as space heaters, to provide heat or cooling without approval from a building inspector. Ms. Nicole Gaines, administrator stated during the visit that the facility temperature can be maintained between 65 to 85 degrees Fahrenheit without the use of space heaters on the left side of the building. Space heaters were removed from the facility during the visit. Issues within the building can occur that you cannot control such as loss of heat/air, electricity, water, and sewer issues. You can create a policy to follow in events such as these that will guide administrators and staff on the protocol to follow, the contacts to be made (including telephone numbers for agencies and individuals), and include a form for documentation. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Contact me at Melinda Lescar, Child Care Consultant (336) 987-0960, Melinda.lescar@dhhs.nc.gov or (Pam Hauser, Licensing Supervisor, (336) 317-5003, pamela.hauser@dhhs.nc.org) if you have questions. 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: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 10/15/2025 Number Present: 20 Completed Date: 10/15/2025 Age: From 0 To 9 Total Minutes: 145 Time In: 10:00 AM Time Out: 12:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with applicable child care requirements during the third temporary time period and to discuss the rated license assessment for the issuance of a star rated license. The visit was conducted with Keeyama Williams-Mumford, owner. Currently this center operates with a Temporary License, issued on May 27, 2025. The restrictions are daytime care only and no cooking allowed in building. The program is approved to operate five classrooms within the building and is licensed to provide care to children ages zero to twelve years old, with a capacity of 100. The Leading Legacy Academy, LLC, owner of the program, is current on all required documents and active on the NC Business Registry. If any changes are made regarding the ownership of this facility, you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. The following items were monitored during today’s visit: •License Posted •Permit Restrictions •Staff/Child Ratios •Supervision •Group Size •Capacity •Hazardous Product Storage •New Staff Files (none provided) •Indoor and Outdoor Space •Safety Requirements •Applicable Rated License Requirements Children in care were observed to be engaged in diapering, in cribs, in bucket containers, eating breakfast, being fed breakfast, engaged in free choice activities, and outdoor play. Two school-age children aged nine-years-old and five-years-old were observed alone (without an adult caregiver) in their assigned classroom. Ms. Williams-Mumford has a registered private school that school aged children attend during the day. However, the assigned teacher was acting as a caregiver in the infant classroom, therefore the school was not in operation. The caregiver assigned to the school age classroom today was in the kitchen. Ms. Williams-Mumford stated that normally the school aged children will go into the kitchen with the caregiver, and we discussed today that this can never occur when the caregiver is also acting as a cook for the facility. Children may never be in the kitchen without it being a supervised approved activity by your sanitation inspector. Four children who are one year old were in care with four children who are three years old with one assigned caregiver. Ms. Williams-Mumford moved the four children who were one year old to a separate classroom with the caregiver who was previously providing care for the school age children. The two school age children were moved into the classroom with the three-year-old children. While typing the visit summary in the office inside the school age classroom, a three-year-old child ran into the classroom alone. I walked the child back to his caregiver. Technical assistance has previously been provided regarding supervision and staff/child ratio violations documented in the classroom where infants and one year old children were in care. You previously submitted compliance documentation stating how you corrected those violations. We discussed today not accepting children for care when there are not enough staff present to maintain staff/child ratios and that children should never be left alone. Violation Number Comment Rule 303 Children were not adequately supervised at all times. Two children ages nine-years-old and five-years-old were alone in Space 5 and the assigned caregiver was located in the kitchen. One child age three-years-old ran out of Space 2 alone and into an empty classroom. I walked the child back to the child's caregiver. .1801(a)(1-5) 318 Children between 12 and 24 months of age were grouped with children 3 years of age or older. Four children who are one year old were grouped with four children who are three years old in Space 2, three hours after the facility opening time. 10A NCAC 09 .0713(a)(6) The compliance history prior to today’s visit was 75 percent. During the last visit, we reviewed that a proposed Denial of License must be submitted if the compliance history falls below 75 percent and if there are serious repeated violations. Due to violations regarding supervision and staff/child ratios we did not discuss the Rated License Assessment during this visit. I would encourage you to complete the staff and training worksheet left with you on September 17, 2025,and enter all staff information, ensure all staff have WORKS accounts with current education information, and to submit the documents required for Pathway #2 that you have selected. All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by October 29, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov. Include in the documentation the following: 1.Name of your facility and ID# 2.Date of the Visit 3.Date of the Documentation you are submitting 4.Each Item Number of the Violations Cited 5.Date of when each item number was corrected 6.How the item was corrected 7.Signature of the person submitting the documentation If you have any questions about today’s visit, please contact Ms. Childress at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding today’s visit or regarding any violations documented during today's visit. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0606 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 8/28/2025 Number Present: 21 Completed Date: 8/28/2025 Age: From 0 To 9 Total Minutes: 163 Time In: 10:42 AM Time Out: 01:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the second temporary time period visit. Upon my arrival, the visit was initiated with Melody Wheeler, staff member, and Nicole Gaines, Administrator, arrived at the facility within 20 minutes. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children aged zero to twelve-years-old and is approved to operate five classrooms within the building with a capacity of one hundred. Restrictions are daytime care only and no cooking allowed in building. The Secretary of State website was checked today, and the owner, the Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. During the visit there were three classrooms in operation and children aged zero to nine-years-old were in care. A fourth classroom was opened during the visit and staff moved the one-year-old children into this space for care so that staff/child ratios were in compliance for the infant children present today. All designated indoor and outdoor spaces for childcare were monitored today. All staff files, a percentage of children’s files and program records will be monitored during a follow-up visit. All documents required to be posted were observed in the center lobby. The facility does not provide transportation. There were no observed changes to the playground area since the pre-licensing and first temporary period visits. Ms. Williams-Mumford provided information today during a telephone call with me while I was on-site, that the school age children present today are attending private school at the facility. She stated that the private school is registered as The Leading Legacy Academy. These children are also enrolled in childcare. The private school operates from 8:00a.m. to 1:30p.m. and the children are then in the licensed childcare program. Pre-packaged breakfast items and snacks are provided to children by the facility and lunch meals are catered by J. Butlers restaurant. During today’s visit children present were observed to be engaged in group and free choice activities, personal care routines, outdoor play, lunch, and nap. The lunch served was chicken tenders, mashed potatoes, mixed vegetables (peas and carrots) and milk. The following violations were cited during today’s visit: Violation Number Comment Rule 205 Storage space was not available for each child's personal belongings. A storage cube, identified by staff, as an enrolled child's personal storage space contained items not belonging to the child such as "Lysol Brand New Day" Disinfecting Wipes, two plastic unlabeled sandwich baggies containing crackers and cookies that belonged to a staff member, a lanyard with attached pepper spray that belonged to a staff member, other children's clothing and shoes, a magnetic key lock for one of the cabinets in the diapering or food prep rooms, unlabeled pacifiers, a container of Gerber Baby Food Blueberry Puffs that staff stated were for all children in the classroom, a package of "Boogie Wipes" not labeled with a child's name, and a sippy cup filled with clear liquid with a different child's name on the cup. G.S. 110-91(6) 301 Minimum staff/child ratios and group sizes for the number and ages of children in care were not met. Twelve children ages zero to one-years-old were in combined care in Space 1 A/B with two staff members. GS 110-91(7);.0713(a-d) 303 Children were not adequately supervised at all times. One-year-old children in care in Space 1 A/B were observed walking alone into the food preparation area, walking out the classroom door, which was open, into the hallway alone, pulling other children's hair, and playing over and lying on an infant that was engaged in tummy time. The inside of the infant cribs could not be seen by staff in the main caregiving area due to crib placement in the classroom. .1801(a)(1-5) 428 A current activity plan was not posted for each group of children for reference. Activity plans posted in classrooms where children ages zero to four-years-old were in care were dated August 11, 2025 through August 15, 2025. A blank activity plan was posted in the classroom where school age children are in care. GS 110-91(12); .0508(a) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Eight bottles for three infants in care in Space 1 A/B were not dated. Three additional bottles for two other infants in care in the same space were not labeled or dated. 15A NCAC 18A .2804(d) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. Weeds were growing inside the fenced-in mulched play area and along the fence line. A low hanging tree branch was hanging into the play area. 15A NCAC 18A .2832(a) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A bottle of foaming hand sanitizer, a box of Ziplock Gallon size Storage Bags, and a package of Parent's Choice Diaper Wipes, all with Keep Out of Reach of Children warnings, were placed on a low shelf and accessible to children in Space 1 A/B. Parents Choice Diaper Wipes were on the countertop of the hallway bathroom used by children. .0604(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A staff members personal lanyard with keys had an attached button pouch containing pepper spray and was stored inside an enrolled child's storage cube sitting on a low, accessible to children, storage shelf. A container of "Lysol Brand New Day" disinfecting wipes were also stored in the child's storage cube. Also on top of the same low shelf were two spray bottles that were labeled and contained Disinfectant. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. A tube of Boudreaux's Butt Paste diaper cream and a tube of Baby Organics sunscreen were in a storage cube sitting on a low shelf and were not made inaccessible to children according to the requirements of Sanitation Rule 15A NCAC 18A .2820(d). 15A NCAC 18A .2820(d) 871 Center staff did not comply with the safe sleep policy. An infant in care in Space 1 A/B was observed asleep in a swing and covered by a blanket at collarbone level. 10A NCAC 09 .0606(a) 887 Caregivers did not document compliance with visually checking on sleeping infants aged 12 months or younger and/or the documents were not maintained for a minimum of one month. Safe sleep charts documenting staff members visual checks of sleeping infants had not been completed for a period of one to two weeks while enrolled infants were in care in Space 1 A/B. .0606(g) All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by September 11, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov using the same format we have already reviewed. Technical Assistance and/or Consultation were provided during today’s visit on the following: Violations in the infant children’s classroom and food prep area were discussed with the assigned caregivers, Ms. Wheeler and Ms. Gaines and were also reviewed by telephone with Ms. Williams-Mumford during the visit: •There were 9 infants in care today. Safe sleep check forms were observed for 10 enrolled infants, and the last documented safe sleep checks are as follows: Child 1 last documented 8/7/25 (Ms. Gaines and Ms. Williams-Mumford stated this child had been absent from care for a few weeks). Child 2 last documented 8/18/25 Child 3 last documented 8/20/25 Child 4 last documented 8/20/25 Child 5 last documented 8/21/25 Child 6 last documented 8/21/25 Child 7 last documented 8/21/25 Child 8 last documented 8/21/25 Child 9 last documented 8/21/25 Child 10 last documented 8/22/25 Staff members’ names and initials on the Safe Sleep Check forms that had been completed were not the assigned caregivers during today’s visit. When staff members caring for infant children today were asked about safe sleep check forms for today, one of the staff members stated none of the infants had been asleep today. One infant was observed to be asleep in a swing with a blanket placed on the child at collarbone level. One of the assigned caregivers was the parent of this child. When asked both caregivers state they had completed ITS-SIDS training and one of the caregivers stated she had previous work experience in licensed child care, but not as an infant caregiver. •The nine infants in care were grouped with three children who were one year old. A total of twelve children were in care in the space with two caregivers. The applicable staff/child ratio form was posted in the classroom showing a staff ratio for children ages 0-12 months old as 1 staff person for every five children and a maximum group size of 10 children. The box for Enhanced Requirements was checked on the form. One staff member went to prepare a bottle in the food prep area (not visible from the classroom) leaving one staff member with 11 children on more than one occasion during the visit. The three children who are one year old were mobile and active, walking around the classroom, into the food preparation area, out the classroom door, which was open, into the hallway, pulling hair, and playing over and lying on an infant that was engaged in tummy time. I explained to the caregivers that staff/child ratio was not in compliance and brought the children’s behavior to their attention as it occurred. One of the assigned caregivers stated that they had decided to group the children today. •One infant was asleep in a swing with a blanket on the child for more than 20 minutes. This infant was the child of one of the assigned caregivers. After I verbally brought this to the attention of the staff, the child was removed from the swing, and the blanket was removed. The safe sleep policy was posted in the classroom, noting that infants are not placed in safety seats, strollers, swings, or infant carriers to sleep, that approved sleeping devices (CPSC) are used, and that objects such as pillows, blankets, or toys in the crib or sleep space are not allowed. •Cribs were observed to be placed away from the primary caregiving area in the classroom and were not arranged in a manner that would allow appropriate supervision. •Eight bottles for three of the infants present were not dated. Three additional bottles were not labeled or dated. These three bottles were for infants belonging to one of the assigned caregivers. There were labels and a Sharpie marker on a tabletop shelf in the food prep area. One of the assigned caregivers stated during morning drop-off that the parent of one of the children stated he had not dated the bottles, and she had forgotten to date the bottles. •The mini refrigerator in the food prep room containing the infant's bottles had a stem thermometer at the bottom of the refrigerator that read 160 degrees. One bottle that was stored on its side at the bottom of the refrigerator had leaked formula into the bottom of the refrigerator. The stem thermometer was replaced with a digital thermometer by Ms. Gaines during the visit. Ms. Wheeler also cleaned up the spilled formula. •Collapsible cube organizers inside a low storage shelf are used to store the belongings for each of the enrolled infants. One’s enrolled infant’s cube (child identified by staff) was sitting on top of the shelf that could be easily accessed by some of the mobile children and contained the following items: A container of Lysol “Brand New Day” disinfecting wipes A tube of Boudreaux’s Butt Paste with “EC” written on the tube A tube of Baby Organics sunscreen with “EC” written on the tube Two Pacifiers not labeled Boy’s clothes, shoes and underwear Girl’s clothing and shoes An unlabeled sandwich baggie of cheddar crackers shaped like turtles An unlabeled sandwich baggie of teddy bears shaped cookies An unlabeled container of Gerber Baby Food Blueberry Puffs (puffed grain snack) A sippy cup of what appeared to be water labeled with a child’s name (not the child for this assigned cube) A package of “Boogie Wipes” Gentle Saline Nose Wipes not labeled with a child's name A magnetic cabinet door lock that staff stated was for a cabinet in the diapering or food prep rooms A lanyard with keys with an attached button pouch containing a cylinder of pepper spray One of the assigned caregivers stated that the crackers and cookies belonged to her, the Gerber puff snacks were for all the children, and the keys belonged to the other assigned caregiver. This caregiver stated that when they clean up the room, everything was usually thrown into this cube. This staff member removed the keys with the pepper spray pouch, acknowledging that these should be locked up, and took them to the food prep room and hung them on a wall hook. The cube was also taken into the room and placed on the floor. The food prep room was not locked, the door was open, and two of the one-year-old children were walking in and out of the room. Ms. Gaines placed all of the items, including the staff member’s keys, in a locked storage closet that is inside the food prep room. When Ms. Gaines and I returned later to the food prep room to check the temperature of the refrigerator on the digital thermometer she had placed in the refrigerator, the storage door was unlocked and partially open. Ms. Gaines closed and locked the door again. •Above the low shelf (lower than five feet) with cubicles for the children’s belongings was a wall mounted dry erase board where staff wrote information about children’s feedings and diapering. On top of the shelf and accessible to the children was a package of Parent’s Choice Diaper Wipes which was labeled Keep Out of Reach of Children. I observed one of the staff members wipe off the dry erase board with one of the wipes and lay the used wipe down on top of the package of wipes. The shelf also had a bottle of foaming hand sanitizer labeled Keep Out of Reach of Children, a box of Ziplock Gallon Storage bags labeled To Avoid Suffocation Keep Out of Reach of Children, and two clear spray bottles containing liquid and labeled “Disinfectant.” One pacifier and one pacifier attached to a bib were also lying on top of the shelf. One of the caregivers stated that she knew the name of the child that the single pacifier belonged to but did not know the name of the child the pacifier attached to the bib belonged to. •The posted activity plan was dated August 11, 2025, through August 15, 2025. (Activity plans for the one-year-old children and three- and four-year-old children had the same dates, and a blank activity plan was posted for the school age children). •A posted attendance form was last completed on August 22, 2025. Parents sign children in and out of the facility on a tablet device in the lobby and Ms. Gaines and Ms. Williams-Mumford stated this is also used as the attendance for each classroom, but they prefer that staff also keep a written attendance in the classroom. •The one-year-old children (three in total) were moved from the infant children’s classroom to another classroom with a different caregiver during the visit. Prior to the children coming into the classroom, I monitored the room with Ms. Gaines. Ms. Gaines removed and locked up a bottle of “Play Day Bubble Blast Solution” for children ages three and up that was sitting on top of a child sized toy shelf. Warnings on the bottle included: Adult Supervision, Do Not Ingest, and In Case of Eye Contact Wash Out with Water. This classroom does not have a diaper changing area or sink. The staff member will have to take all the children back to the infant children’s classroom for diapering and handwashing and we discussed that the three children would not always need a diaper change at the same time. Ms. Gaines stated that none of these children had bottles. All children, but especially infants and young toddlers, are solely dependent on their caregivers for the completion of personal care routines (feeding, changing), interaction, and the assurance of a safe and healthy environment. Every responsibility when caring for these groups of children, is comprised when staff/child ratios are not in compliance, group size is exceeded, safe sleep checks are not completed, the safe sleep policy is not followed, and a safe and healthy environment is not maintained. I discussed my recommendation with Ms. Williams-Mumford that she contact Child Care Resource Center and speak with an Infant-Toddler Specialist and ask for a visit to the classroom to address these issues. We also discussed room arrangement and that the large, open, expansive classroom designated for the infant children could be divided by low shelves (like was observed during the pre-licensing visits) and the one-year-old children could be in a designated half of the classroom allowing their caregiver to have access to the diapering room and sinks. Ms. Gaines stated that they had ensured that a floater was always present to assist in all of classrooms as needed. Ms. Williams-Mumford stated that there had been unavoidable staff turnover as I stated that there was an obvious change in the last few weeks when attendance and safe sleep charts were not being completed. Ms. Williams-Mumford stated that she is affected by the staff shortage crisis and the quality and experience of persons who apply for positions. Diaper wipes in the hallway bathrooms were on the countertop and otherwise not stored at five vertical feet above the floor and had a Keep Out of Reach of Children warning label. As previously noted, activity plans for all groups of children were not current and/or posted for the past week. The playground had visible weeds inside the fenced in mulched play area, and along the fence line. A low hanging tree branch was hanging inside the play area. Ms. Williams-Mumford stated that these issues would be taken care of on Saturday when the lawn/landscape maintenance personnel came. She stated that they come every other week. I stated that the height and excessive growth of the weeds appeared to have not been addressed in the last two weeks. Your compliance history affects the star rating. It is imperative that all staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During today’s visit we again discussed the Rated License Assessment Process. On June 27, 2025, Ms. Williams-Mumford replied to an email I sent regarding the QRIS Modernization rules and processes, and she stated that she wished to proceed with the updated QRIS Modernization and would pursue Pathway 2. On August 24, 2025, I emailed her the most current Rated License Application, along with guideline for completing the requirements for Pathway 2 at each star level. Ms. Williams-Mumford will complete the application for a Star Rated License Assessment today and email it to me. You should also contact your local resource and referral agency for additional resources and technical assistance: Smart Start of Forsyth County 336-725-6011 https://smartstart-fc.org/ Education for staff will be assessed as part of the rated license. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the education rating for your staff members and for your rated license. Instructions for the DCDEE WORKS system is located on the DCDEE website at https://ncchildcare.ncdhhs.gov. Child Care Rules Chapter 9- Child Care Rules has been updated, effective July 1, 2025. Please review the rules and save a copy to your desktop or other file for quick reference. The Chapter 9- Child Care Rules can be found on the DCDEE website at https://ncchildcare.ncdhhs.gov, under the “Provider” tab in the home screen and selecting “Child Care Rules.” Health and Safety Training All staff must complete Health and Safety Trainings within one year of hire and must be repeated every five years with training certificates on file for review. These trainings can be accessed on the DCDEE website at https://ncchildcare.ncdhhs.gov under the Provider tab from the home screen, select Training and Professional Development, and finally DCDEE Moodle. If you need assistance in locating the trainings, please contact me. It is important to remember that the childcare administrator and all staff members must complete the specific Health and Safety Training called “Recognizing and Responding to Suspicions of Child Maltreatment”, within 90 days of employment. This training can be accessed through Moodle or directly at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. Orientation For New Staff/ New Staff Files/ CPR/FA and Trainings Health and safety training shall be in addition to the new staff orientation requirements. Orientation topics should be a review of the policies specific to your facility. All staff, including the director, must receive 16 hours of orientation. The orientation form is available on the DCDEE website www.ncchildcare.ncdhhs.gov under provider documents and forms. All documents listed on the staff file checklist must be in staff files and available for review. All CPR/FA training must be in-person by an approved training. Online CPR/FA courses will not be accepted. On-Going Professional Development. If staff complete approved college courses in child development, for every one college credit hour (CEU) completed staff will earn 16 hours of on-going training. All staff must complete the required number of on-going training hours based upon education and experience within one year of hire and annually. The required number of training hours can be determined for each staff member using the information provided in Child Care Rule 10A NCAC 09 .1103. Staff development trainings should include content on the following: Planning a safe, healthy learning environment Steps to advance children's physical and intellectual development Positive ways to support children's social and emotional Strategies to establish productive relationships with families Strategies to manage an effective program operation Maintaining a commitment to professionalism Observing and recording children's behavior Principles of child growth and development Learning activities that promote inclusion of children with special In addition to the required Health and Safety Trainings, staff can access professional development training on Moodle under Early Childhood Professional Development in the categories of Child Care and Development Fund (CCDF), Orientation and Regulatory. Updated training modules are being added, including a child care rule rollout with new rules effective July 1, 2025. An individual NCID username and password is needed to access DCDEE Moodle. If you experience problems with Moodle, contact dcdee_moodle_support@dhhs.nc.gov for assistance. For other training-related questions, please contact the Training and Program Development Consultant, Amia Eaton by calling (919) 814-6365 or emailing her at Amia.Eaton@dhhs.nc.gov. Specifically, under the Orientation section, I would encourage all staff to complete the training for “Child Development Module.” This training module provides a basic overview about child development and is designed to help early educators support infants, toddlers, and preschool children to reach their next developmental milestone. In addition to gaining introductory knowledge about child development, early educators will learn about the many resources and professional agencies available in North Carolina to help with promoting a responsive and engaging learning environment to support all children served. Upon completion, participants will receive one (1) contact hour credit (CHC). Staff Development Plan and Annual Evaluation All staff members must complete a Professional Development Plan and receive an annual evaluation within one year of hire. A sample staff development plan is available on the DCDEE website under Provider Documents and Forms. The Staff Development Plan and the annual evaluation are two different requirements. The purpose of the Staff Development Plan is to review staff goals and to see if these goals have been met, and to set new professional goals each year. The staff evaluation is to review each staff member’s job performance and to identify areas where the staff member is excelling and the areas where performance should be improved. For some areas for improvements that are of concern regarding the health and safety of children, a specific plan of action should be clearly outlined and show the plan will be monitored. I could not access the VPN or the Regulatory System to complete a computer-generated visit summary while at the facility. All observed violations and technical assistance were discussed with Ms. Gaines and Ms. Williams-Mumford during the visit. A handwritten visit summary was completed with Ms. Gaines, and a completed computer-generated visit summary will be emailed to her and Ms. Williams-Mumford following today’s visit. An email was sent to Ms. Williams-Mumford at 5:57pm explaining that I continued to have repeated issues with accessing the required systems and would email the visit summary as soon as possible. Ms. Williams-Mumford sent a reply email with the completed Rated License application and stated that she would be conducting a mandatory staff meeting tomorrow, August 29, 2025. This visit summary was completed and emailed to Ms. Gaines and Ms. Williams-Mumford on August 29, 2025. If you have any questions about the visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding the visit or any violations documented. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .1103 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 8/28/2025 Number Present: 21 Completed Date: 8/28/2025 Age: From 0 To 9 Total Minutes: 163 Time In: 10:42 AM Time Out: 01:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the second temporary time period visit. Upon my arrival, the visit was initiated with Melody Wheeler, staff member, and Nicole Gaines, Administrator, arrived at the facility within 20 minutes. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children aged zero to twelve-years-old and is approved to operate five classrooms within the building with a capacity of one hundred. Restrictions are daytime care only and no cooking allowed in building. The Secretary of State website was checked today, and the owner, the Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. During the visit there were three classrooms in operation and children aged zero to nine-years-old were in care. A fourth classroom was opened during the visit and staff moved the one-year-old children into this space for care so that staff/child ratios were in compliance for the infant children present today. All designated indoor and outdoor spaces for childcare were monitored today. All staff files, a percentage of children’s files and program records will be monitored during a follow-up visit. All documents required to be posted were observed in the center lobby. The facility does not provide transportation. There were no observed changes to the playground area since the pre-licensing and first temporary period visits. Ms. Williams-Mumford provided information today during a telephone call with me while I was on-site, that the school age children present today are attending private school at the facility. She stated that the private school is registered as The Leading Legacy Academy. These children are also enrolled in childcare. The private school operates from 8:00a.m. to 1:30p.m. and the children are then in the licensed childcare program. Pre-packaged breakfast items and snacks are provided to children by the facility and lunch meals are catered by J. Butlers restaurant. During today’s visit children present were observed to be engaged in group and free choice activities, personal care routines, outdoor play, lunch, and nap. The lunch served was chicken tenders, mashed potatoes, mixed vegetables (peas and carrots) and milk. The following violations were cited during today’s visit: Violation Number Comment Rule 205 Storage space was not available for each child's personal belongings. A storage cube, identified by staff, as an enrolled child's personal storage space contained items not belonging to the child such as "Lysol Brand New Day" Disinfecting Wipes, two plastic unlabeled sandwich baggies containing crackers and cookies that belonged to a staff member, a lanyard with attached pepper spray that belonged to a staff member, other children's clothing and shoes, a magnetic key lock for one of the cabinets in the diapering or food prep rooms, unlabeled pacifiers, a container of Gerber Baby Food Blueberry Puffs that staff stated were for all children in the classroom, a package of "Boogie Wipes" not labeled with a child's name, and a sippy cup filled with clear liquid with a different child's name on the cup. G.S. 110-91(6) 301 Minimum staff/child ratios and group sizes for the number and ages of children in care were not met. Twelve children ages zero to one-years-old were in combined care in Space 1 A/B with two staff members. GS 110-91(7);.0713(a-d) 303 Children were not adequately supervised at all times. One-year-old children in care in Space 1 A/B were observed walking alone into the food preparation area, walking out the classroom door, which was open, into the hallway alone, pulling other children's hair, and playing over and lying on an infant that was engaged in tummy time. The inside of the infant cribs could not be seen by staff in the main caregiving area due to crib placement in the classroom. .1801(a)(1-5) 428 A current activity plan was not posted for each group of children for reference. Activity plans posted in classrooms where children ages zero to four-years-old were in care were dated August 11, 2025 through August 15, 2025. A blank activity plan was posted in the classroom where school age children are in care. GS 110-91(12); .0508(a) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Eight bottles for three infants in care in Space 1 A/B were not dated. Three additional bottles for two other infants in care in the same space were not labeled or dated. 15A NCAC 18A .2804(d) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. Weeds were growing inside the fenced-in mulched play area and along the fence line. A low hanging tree branch was hanging into the play area. 15A NCAC 18A .2832(a) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A bottle of foaming hand sanitizer, a box of Ziplock Gallon size Storage Bags, and a package of Parent's Choice Diaper Wipes, all with Keep Out of Reach of Children warnings, were placed on a low shelf and accessible to children in Space 1 A/B. Parents Choice Diaper Wipes were on the countertop of the hallway bathroom used by children. .0604(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A staff members personal lanyard with keys had an attached button pouch containing pepper spray and was stored inside an enrolled child's storage cube sitting on a low, accessible to children, storage shelf. A container of "Lysol Brand New Day" disinfecting wipes were also stored in the child's storage cube. Also on top of the same low shelf were two spray bottles that were labeled and contained Disinfectant. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. A tube of Boudreaux's Butt Paste diaper cream and a tube of Baby Organics sunscreen were in a storage cube sitting on a low shelf and were not made inaccessible to children according to the requirements of Sanitation Rule 15A NCAC 18A .2820(d). 15A NCAC 18A .2820(d) 871 Center staff did not comply with the safe sleep policy. An infant in care in Space 1 A/B was observed asleep in a swing and covered by a blanket at collarbone level. 10A NCAC 09 .0606(a) 887 Caregivers did not document compliance with visually checking on sleeping infants aged 12 months or younger and/or the documents were not maintained for a minimum of one month. Safe sleep charts documenting staff members visual checks of sleeping infants had not been completed for a period of one to two weeks while enrolled infants were in care in Space 1 A/B. .0606(g) All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by September 11, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov using the same format we have already reviewed. Technical Assistance and/or Consultation were provided during today’s visit on the following: Violations in the infant children’s classroom and food prep area were discussed with the assigned caregivers, Ms. Wheeler and Ms. Gaines and were also reviewed by telephone with Ms. Williams-Mumford during the visit: •There were 9 infants in care today. Safe sleep check forms were observed for 10 enrolled infants, and the last documented safe sleep checks are as follows: Child 1 last documented 8/7/25 (Ms. Gaines and Ms. Williams-Mumford stated this child had been absent from care for a few weeks). Child 2 last documented 8/18/25 Child 3 last documented 8/20/25 Child 4 last documented 8/20/25 Child 5 last documented 8/21/25 Child 6 last documented 8/21/25 Child 7 last documented 8/21/25 Child 8 last documented 8/21/25 Child 9 last documented 8/21/25 Child 10 last documented 8/22/25 Staff members’ names and initials on the Safe Sleep Check forms that had been completed were not the assigned caregivers during today’s visit. When staff members caring for infant children today were asked about safe sleep check forms for today, one of the staff members stated none of the infants had been asleep today. One infant was observed to be asleep in a swing with a blanket placed on the child at collarbone level. One of the assigned caregivers was the parent of this child. When asked both caregivers state they had completed ITS-SIDS training and one of the caregivers stated she had previous work experience in licensed child care, but not as an infant caregiver. •The nine infants in care were grouped with three children who were one year old. A total of twelve children were in care in the space with two caregivers. The applicable staff/child ratio form was posted in the classroom showing a staff ratio for children ages 0-12 months old as 1 staff person for every five children and a maximum group size of 10 children. The box for Enhanced Requirements was checked on the form. One staff member went to prepare a bottle in the food prep area (not visible from the classroom) leaving one staff member with 11 children on more than one occasion during the visit. The three children who are one year old were mobile and active, walking around the classroom, into the food preparation area, out the classroom door, which was open, into the hallway, pulling hair, and playing over and lying on an infant that was engaged in tummy time. I explained to the caregivers that staff/child ratio was not in compliance and brought the children’s behavior to their attention as it occurred. One of the assigned caregivers stated that they had decided to group the children today. •One infant was asleep in a swing with a blanket on the child for more than 20 minutes. This infant was the child of one of the assigned caregivers. After I verbally brought this to the attention of the staff, the child was removed from the swing, and the blanket was removed. The safe sleep policy was posted in the classroom, noting that infants are not placed in safety seats, strollers, swings, or infant carriers to sleep, that approved sleeping devices (CPSC) are used, and that objects such as pillows, blankets, or toys in the crib or sleep space are not allowed. •Cribs were observed to be placed away from the primary caregiving area in the classroom and were not arranged in a manner that would allow appropriate supervision. •Eight bottles for three of the infants present were not dated. Three additional bottles were not labeled or dated. These three bottles were for infants belonging to one of the assigned caregivers. There were labels and a Sharpie marker on a tabletop shelf in the food prep area. One of the assigned caregivers stated during morning drop-off that the parent of one of the children stated he had not dated the bottles, and she had forgotten to date the bottles. •The mini refrigerator in the food prep room containing the infant's bottles had a stem thermometer at the bottom of the refrigerator that read 160 degrees. One bottle that was stored on its side at the bottom of the refrigerator had leaked formula into the bottom of the refrigerator. The stem thermometer was replaced with a digital thermometer by Ms. Gaines during the visit. Ms. Wheeler also cleaned up the spilled formula. •Collapsible cube organizers inside a low storage shelf are used to store the belongings for each of the enrolled infants. One’s enrolled infant’s cube (child identified by staff) was sitting on top of the shelf that could be easily accessed by some of the mobile children and contained the following items: A container of Lysol “Brand New Day” disinfecting wipes A tube of Boudreaux’s Butt Paste with “EC” written on the tube A tube of Baby Organics sunscreen with “EC” written on the tube Two Pacifiers not labeled Boy’s clothes, shoes and underwear Girl’s clothing and shoes An unlabeled sandwich baggie of cheddar crackers shaped like turtles An unlabeled sandwich baggie of teddy bears shaped cookies An unlabeled container of Gerber Baby Food Blueberry Puffs (puffed grain snack) A sippy cup of what appeared to be water labeled with a child’s name (not the child for this assigned cube) A package of “Boogie Wipes” Gentle Saline Nose Wipes not labeled with a child's name A magnetic cabinet door lock that staff stated was for a cabinet in the diapering or food prep rooms A lanyard with keys with an attached button pouch containing a cylinder of pepper spray One of the assigned caregivers stated that the crackers and cookies belonged to her, the Gerber puff snacks were for all the children, and the keys belonged to the other assigned caregiver. This caregiver stated that when they clean up the room, everything was usually thrown into this cube. This staff member removed the keys with the pepper spray pouch, acknowledging that these should be locked up, and took them to the food prep room and hung them on a wall hook. The cube was also taken into the room and placed on the floor. The food prep room was not locked, the door was open, and two of the one-year-old children were walking in and out of the room. Ms. Gaines placed all of the items, including the staff member’s keys, in a locked storage closet that is inside the food prep room. When Ms. Gaines and I returned later to the food prep room to check the temperature of the refrigerator on the digital thermometer she had placed in the refrigerator, the storage door was unlocked and partially open. Ms. Gaines closed and locked the door again. •Above the low shelf (lower than five feet) with cubicles for the children’s belongings was a wall mounted dry erase board where staff wrote information about children’s feedings and diapering. On top of the shelf and accessible to the children was a package of Parent’s Choice Diaper Wipes which was labeled Keep Out of Reach of Children. I observed one of the staff members wipe off the dry erase board with one of the wipes and lay the used wipe down on top of the package of wipes. The shelf also had a bottle of foaming hand sanitizer labeled Keep Out of Reach of Children, a box of Ziplock Gallon Storage bags labeled To Avoid Suffocation Keep Out of Reach of Children, and two clear spray bottles containing liquid and labeled “Disinfectant.” One pacifier and one pacifier attached to a bib were also lying on top of the shelf. One of the caregivers stated that she knew the name of the child that the single pacifier belonged to but did not know the name of the child the pacifier attached to the bib belonged to. •The posted activity plan was dated August 11, 2025, through August 15, 2025. (Activity plans for the one-year-old children and three- and four-year-old children had the same dates, and a blank activity plan was posted for the school age children). •A posted attendance form was last completed on August 22, 2025. Parents sign children in and out of the facility on a tablet device in the lobby and Ms. Gaines and Ms. Williams-Mumford stated this is also used as the attendance for each classroom, but they prefer that staff also keep a written attendance in the classroom. •The one-year-old children (three in total) were moved from the infant children’s classroom to another classroom with a different caregiver during the visit. Prior to the children coming into the classroom, I monitored the room with Ms. Gaines. Ms. Gaines removed and locked up a bottle of “Play Day Bubble Blast Solution” for children ages three and up that was sitting on top of a child sized toy shelf. Warnings on the bottle included: Adult Supervision, Do Not Ingest, and In Case of Eye Contact Wash Out with Water. This classroom does not have a diaper changing area or sink. The staff member will have to take all the children back to the infant children’s classroom for diapering and handwashing and we discussed that the three children would not always need a diaper change at the same time. Ms. Gaines stated that none of these children had bottles. All children, but especially infants and young toddlers, are solely dependent on their caregivers for the completion of personal care routines (feeding, changing), interaction, and the assurance of a safe and healthy environment. Every responsibility when caring for these groups of children, is comprised when staff/child ratios are not in compliance, group size is exceeded, safe sleep checks are not completed, the safe sleep policy is not followed, and a safe and healthy environment is not maintained. I discussed my recommendation with Ms. Williams-Mumford that she contact Child Care Resource Center and speak with an Infant-Toddler Specialist and ask for a visit to the classroom to address these issues. We also discussed room arrangement and that the large, open, expansive classroom designated for the infant children could be divided by low shelves (like was observed during the pre-licensing visits) and the one-year-old children could be in a designated half of the classroom allowing their caregiver to have access to the diapering room and sinks. Ms. Gaines stated that they had ensured that a floater was always present to assist in all of classrooms as needed. Ms. Williams-Mumford stated that there had been unavoidable staff turnover as I stated that there was an obvious change in the last few weeks when attendance and safe sleep charts were not being completed. Ms. Williams-Mumford stated that she is affected by the staff shortage crisis and the quality and experience of persons who apply for positions. Diaper wipes in the hallway bathrooms were on the countertop and otherwise not stored at five vertical feet above the floor and had a Keep Out of Reach of Children warning label. As previously noted, activity plans for all groups of children were not current and/or posted for the past week. The playground had visible weeds inside the fenced in mulched play area, and along the fence line. A low hanging tree branch was hanging inside the play area. Ms. Williams-Mumford stated that these issues would be taken care of on Saturday when the lawn/landscape maintenance personnel came. She stated that they come every other week. I stated that the height and excessive growth of the weeds appeared to have not been addressed in the last two weeks. Your compliance history affects the star rating. It is imperative that all staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During today’s visit we again discussed the Rated License Assessment Process. On June 27, 2025, Ms. Williams-Mumford replied to an email I sent regarding the QRIS Modernization rules and processes, and she stated that she wished to proceed with the updated QRIS Modernization and would pursue Pathway 2. On August 24, 2025, I emailed her the most current Rated License Application, along with guideline for completing the requirements for Pathway 2 at each star level. Ms. Williams-Mumford will complete the application for a Star Rated License Assessment today and email it to me. You should also contact your local resource and referral agency for additional resources and technical assistance: Smart Start of Forsyth County 336-725-6011 https://smartstart-fc.org/ Education for staff will be assessed as part of the rated license. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the education rating for your staff members and for your rated license. Instructions for the DCDEE WORKS system is located on the DCDEE website at https://ncchildcare.ncdhhs.gov. Child Care Rules Chapter 9- Child Care Rules has been updated, effective July 1, 2025. Please review the rules and save a copy to your desktop or other file for quick reference. The Chapter 9- Child Care Rules can be found on the DCDEE website at https://ncchildcare.ncdhhs.gov, under the “Provider” tab in the home screen and selecting “Child Care Rules.” Health and Safety Training All staff must complete Health and Safety Trainings within one year of hire and must be repeated every five years with training certificates on file for review. These trainings can be accessed on the DCDEE website at https://ncchildcare.ncdhhs.gov under the Provider tab from the home screen, select Training and Professional Development, and finally DCDEE Moodle. If you need assistance in locating the trainings, please contact me. It is important to remember that the childcare administrator and all staff members must complete the specific Health and Safety Training called “Recognizing and Responding to Suspicions of Child Maltreatment”, within 90 days of employment. This training can be accessed through Moodle or directly at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. Orientation For New Staff/ New Staff Files/ CPR/FA and Trainings Health and safety training shall be in addition to the new staff orientation requirements. Orientation topics should be a review of the policies specific to your facility. All staff, including the director, must receive 16 hours of orientation. The orientation form is available on the DCDEE website www.ncchildcare.ncdhhs.gov under provider documents and forms. All documents listed on the staff file checklist must be in staff files and available for review. All CPR/FA training must be in-person by an approved training. Online CPR/FA courses will not be accepted. On-Going Professional Development. If staff complete approved college courses in child development, for every one college credit hour (CEU) completed staff will earn 16 hours of on-going training. All staff must complete the required number of on-going training hours based upon education and experience within one year of hire and annually. The required number of training hours can be determined for each staff member using the information provided in Child Care Rule 10A NCAC 09 .1103. Staff development trainings should include content on the following: Planning a safe, healthy learning environment Steps to advance children's physical and intellectual development Positive ways to support children's social and emotional Strategies to establish productive relationships with families Strategies to manage an effective program operation Maintaining a commitment to professionalism Observing and recording children's behavior Principles of child growth and development Learning activities that promote inclusion of children with special In addition to the required Health and Safety Trainings, staff can access professional development training on Moodle under Early Childhood Professional Development in the categories of Child Care and Development Fund (CCDF), Orientation and Regulatory. Updated training modules are being added, including a child care rule rollout with new rules effective July 1, 2025. An individual NCID username and password is needed to access DCDEE Moodle. If you experience problems with Moodle, contact dcdee_moodle_support@dhhs.nc.gov for assistance. For other training-related questions, please contact the Training and Program Development Consultant, Amia Eaton by calling (919) 814-6365 or emailing her at Amia.Eaton@dhhs.nc.gov. Specifically, under the Orientation section, I would encourage all staff to complete the training for “Child Development Module.” This training module provides a basic overview about child development and is designed to help early educators support infants, toddlers, and preschool children to reach their next developmental milestone. In addition to gaining introductory knowledge about child development, early educators will learn about the many resources and professional agencies available in North Carolina to help with promoting a responsive and engaging learning environment to support all children served. Upon completion, participants will receive one (1) contact hour credit (CHC). Staff Development Plan and Annual Evaluation All staff members must complete a Professional Development Plan and receive an annual evaluation within one year of hire. A sample staff development plan is available on the DCDEE website under Provider Documents and Forms. The Staff Development Plan and the annual evaluation are two different requirements. The purpose of the Staff Development Plan is to review staff goals and to see if these goals have been met, and to set new professional goals each year. The staff evaluation is to review each staff member’s job performance and to identify areas where the staff member is excelling and the areas where performance should be improved. For some areas for improvements that are of concern regarding the health and safety of children, a specific plan of action should be clearly outlined and show the plan will be monitored. I could not access the VPN or the Regulatory System to complete a computer-generated visit summary while at the facility. All observed violations and technical assistance were discussed with Ms. Gaines and Ms. Williams-Mumford during the visit. A handwritten visit summary was completed with Ms. Gaines, and a completed computer-generated visit summary will be emailed to her and Ms. Williams-Mumford following today’s visit. An email was sent to Ms. Williams-Mumford at 5:57pm explaining that I continued to have repeated issues with accessing the required systems and would email the visit summary as soon as possible. Ms. Williams-Mumford sent a reply email with the completed Rated License application and stated that she would be conducting a mandatory staff meeting tomorrow, August 29, 2025. This visit summary was completed and emailed to Ms. Gaines and Ms. Williams-Mumford on August 29, 2025. If you have any questions about the visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding the visit or any violations documented. 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: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 8/28/2025 Number Present: 21 Completed Date: 8/28/2025 Age: From 0 To 9 Total Minutes: 163 Time In: 10:42 AM Time Out: 01:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the second temporary time period visit. Upon my arrival, the visit was initiated with Melody Wheeler, staff member, and Nicole Gaines, Administrator, arrived at the facility within 20 minutes. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children aged zero to twelve-years-old and is approved to operate five classrooms within the building with a capacity of one hundred. Restrictions are daytime care only and no cooking allowed in building. The Secretary of State website was checked today, and the owner, the Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. During the visit there were three classrooms in operation and children aged zero to nine-years-old were in care. A fourth classroom was opened during the visit and staff moved the one-year-old children into this space for care so that staff/child ratios were in compliance for the infant children present today. All designated indoor and outdoor spaces for childcare were monitored today. All staff files, a percentage of children’s files and program records will be monitored during a follow-up visit. All documents required to be posted were observed in the center lobby. The facility does not provide transportation. There were no observed changes to the playground area since the pre-licensing and first temporary period visits. Ms. Williams-Mumford provided information today during a telephone call with me while I was on-site, that the school age children present today are attending private school at the facility. She stated that the private school is registered as The Leading Legacy Academy. These children are also enrolled in childcare. The private school operates from 8:00a.m. to 1:30p.m. and the children are then in the licensed childcare program. Pre-packaged breakfast items and snacks are provided to children by the facility and lunch meals are catered by J. Butlers restaurant. During today’s visit children present were observed to be engaged in group and free choice activities, personal care routines, outdoor play, lunch, and nap. The lunch served was chicken tenders, mashed potatoes, mixed vegetables (peas and carrots) and milk. The following violations were cited during today’s visit: Violation Number Comment Rule 205 Storage space was not available for each child's personal belongings. A storage cube, identified by staff, as an enrolled child's personal storage space contained items not belonging to the child such as "Lysol Brand New Day" Disinfecting Wipes, two plastic unlabeled sandwich baggies containing crackers and cookies that belonged to a staff member, a lanyard with attached pepper spray that belonged to a staff member, other children's clothing and shoes, a magnetic key lock for one of the cabinets in the diapering or food prep rooms, unlabeled pacifiers, a container of Gerber Baby Food Blueberry Puffs that staff stated were for all children in the classroom, a package of "Boogie Wipes" not labeled with a child's name, and a sippy cup filled with clear liquid with a different child's name on the cup. G.S. 110-91(6) 301 Minimum staff/child ratios and group sizes for the number and ages of children in care were not met. Twelve children ages zero to one-years-old were in combined care in Space 1 A/B with two staff members. GS 110-91(7);.0713(a-d) 303 Children were not adequately supervised at all times. One-year-old children in care in Space 1 A/B were observed walking alone into the food preparation area, walking out the classroom door, which was open, into the hallway alone, pulling other children's hair, and playing over and lying on an infant that was engaged in tummy time. The inside of the infant cribs could not be seen by staff in the main caregiving area due to crib placement in the classroom. .1801(a)(1-5) 428 A current activity plan was not posted for each group of children for reference. Activity plans posted in classrooms where children ages zero to four-years-old were in care were dated August 11, 2025 through August 15, 2025. A blank activity plan was posted in the classroom where school age children are in care. GS 110-91(12); .0508(a) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Eight bottles for three infants in care in Space 1 A/B were not dated. Three additional bottles for two other infants in care in the same space were not labeled or dated. 15A NCAC 18A .2804(d) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. Weeds were growing inside the fenced-in mulched play area and along the fence line. A low hanging tree branch was hanging into the play area. 15A NCAC 18A .2832(a) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A bottle of foaming hand sanitizer, a box of Ziplock Gallon size Storage Bags, and a package of Parent's Choice Diaper Wipes, all with Keep Out of Reach of Children warnings, were placed on a low shelf and accessible to children in Space 1 A/B. Parents Choice Diaper Wipes were on the countertop of the hallway bathroom used by children. .0604(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A staff members personal lanyard with keys had an attached button pouch containing pepper spray and was stored inside an enrolled child's storage cube sitting on a low, accessible to children, storage shelf. A container of "Lysol Brand New Day" disinfecting wipes were also stored in the child's storage cube. Also on top of the same low shelf were two spray bottles that were labeled and contained Disinfectant. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. A tube of Boudreaux's Butt Paste diaper cream and a tube of Baby Organics sunscreen were in a storage cube sitting on a low shelf and were not made inaccessible to children according to the requirements of Sanitation Rule 15A NCAC 18A .2820(d). 15A NCAC 18A .2820(d) 871 Center staff did not comply with the safe sleep policy. An infant in care in Space 1 A/B was observed asleep in a swing and covered by a blanket at collarbone level. 10A NCAC 09 .0606(a) 887 Caregivers did not document compliance with visually checking on sleeping infants aged 12 months or younger and/or the documents were not maintained for a minimum of one month. Safe sleep charts documenting staff members visual checks of sleeping infants had not been completed for a period of one to two weeks while enrolled infants were in care in Space 1 A/B. .0606(g) All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by September 11, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov using the same format we have already reviewed. Technical Assistance and/or Consultation were provided during today’s visit on the following: Violations in the infant children’s classroom and food prep area were discussed with the assigned caregivers, Ms. Wheeler and Ms. Gaines and were also reviewed by telephone with Ms. Williams-Mumford during the visit: •There were 9 infants in care today. Safe sleep check forms were observed for 10 enrolled infants, and the last documented safe sleep checks are as follows: Child 1 last documented 8/7/25 (Ms. Gaines and Ms. Williams-Mumford stated this child had been absent from care for a few weeks). Child 2 last documented 8/18/25 Child 3 last documented 8/20/25 Child 4 last documented 8/20/25 Child 5 last documented 8/21/25 Child 6 last documented 8/21/25 Child 7 last documented 8/21/25 Child 8 last documented 8/21/25 Child 9 last documented 8/21/25 Child 10 last documented 8/22/25 Staff members’ names and initials on the Safe Sleep Check forms that had been completed were not the assigned caregivers during today’s visit. When staff members caring for infant children today were asked about safe sleep check forms for today, one of the staff members stated none of the infants had been asleep today. One infant was observed to be asleep in a swing with a blanket placed on the child at collarbone level. One of the assigned caregivers was the parent of this child. When asked both caregivers state they had completed ITS-SIDS training and one of the caregivers stated she had previous work experience in licensed child care, but not as an infant caregiver. •The nine infants in care were grouped with three children who were one year old. A total of twelve children were in care in the space with two caregivers. The applicable staff/child ratio form was posted in the classroom showing a staff ratio for children ages 0-12 months old as 1 staff person for every five children and a maximum group size of 10 children. The box for Enhanced Requirements was checked on the form. One staff member went to prepare a bottle in the food prep area (not visible from the classroom) leaving one staff member with 11 children on more than one occasion during the visit. The three children who are one year old were mobile and active, walking around the classroom, into the food preparation area, out the classroom door, which was open, into the hallway, pulling hair, and playing over and lying on an infant that was engaged in tummy time. I explained to the caregivers that staff/child ratio was not in compliance and brought the children’s behavior to their attention as it occurred. One of the assigned caregivers stated that they had decided to group the children today. •One infant was asleep in a swing with a blanket on the child for more than 20 minutes. This infant was the child of one of the assigned caregivers. After I verbally brought this to the attention of the staff, the child was removed from the swing, and the blanket was removed. The safe sleep policy was posted in the classroom, noting that infants are not placed in safety seats, strollers, swings, or infant carriers to sleep, that approved sleeping devices (CPSC) are used, and that objects such as pillows, blankets, or toys in the crib or sleep space are not allowed. •Cribs were observed to be placed away from the primary caregiving area in the classroom and were not arranged in a manner that would allow appropriate supervision. •Eight bottles for three of the infants present were not dated. Three additional bottles were not labeled or dated. These three bottles were for infants belonging to one of the assigned caregivers. There were labels and a Sharpie marker on a tabletop shelf in the food prep area. One of the assigned caregivers stated during morning drop-off that the parent of one of the children stated he had not dated the bottles, and she had forgotten to date the bottles. •The mini refrigerator in the food prep room containing the infant's bottles had a stem thermometer at the bottom of the refrigerator that read 160 degrees. One bottle that was stored on its side at the bottom of the refrigerator had leaked formula into the bottom of the refrigerator. The stem thermometer was replaced with a digital thermometer by Ms. Gaines during the visit. Ms. Wheeler also cleaned up the spilled formula. •Collapsible cube organizers inside a low storage shelf are used to store the belongings for each of the enrolled infants. One’s enrolled infant’s cube (child identified by staff) was sitting on top of the shelf that could be easily accessed by some of the mobile children and contained the following items: A container of Lysol “Brand New Day” disinfecting wipes A tube of Boudreaux’s Butt Paste with “EC” written on the tube A tube of Baby Organics sunscreen with “EC” written on the tube Two Pacifiers not labeled Boy’s clothes, shoes and underwear Girl’s clothing and shoes An unlabeled sandwich baggie of cheddar crackers shaped like turtles An unlabeled sandwich baggie of teddy bears shaped cookies An unlabeled container of Gerber Baby Food Blueberry Puffs (puffed grain snack) A sippy cup of what appeared to be water labeled with a child’s name (not the child for this assigned cube) A package of “Boogie Wipes” Gentle Saline Nose Wipes not labeled with a child's name A magnetic cabinet door lock that staff stated was for a cabinet in the diapering or food prep rooms A lanyard with keys with an attached button pouch containing a cylinder of pepper spray One of the assigned caregivers stated that the crackers and cookies belonged to her, the Gerber puff snacks were for all the children, and the keys belonged to the other assigned caregiver. This caregiver stated that when they clean up the room, everything was usually thrown into this cube. This staff member removed the keys with the pepper spray pouch, acknowledging that these should be locked up, and took them to the food prep room and hung them on a wall hook. The cube was also taken into the room and placed on the floor. The food prep room was not locked, the door was open, and two of the one-year-old children were walking in and out of the room. Ms. Gaines placed all of the items, including the staff member’s keys, in a locked storage closet that is inside the food prep room. When Ms. Gaines and I returned later to the food prep room to check the temperature of the refrigerator on the digital thermometer she had placed in the refrigerator, the storage door was unlocked and partially open. Ms. Gaines closed and locked the door again. •Above the low shelf (lower than five feet) with cubicles for the children’s belongings was a wall mounted dry erase board where staff wrote information about children’s feedings and diapering. On top of the shelf and accessible to the children was a package of Parent’s Choice Diaper Wipes which was labeled Keep Out of Reach of Children. I observed one of the staff members wipe off the dry erase board with one of the wipes and lay the used wipe down on top of the package of wipes. The shelf also had a bottle of foaming hand sanitizer labeled Keep Out of Reach of Children, a box of Ziplock Gallon Storage bags labeled To Avoid Suffocation Keep Out of Reach of Children, and two clear spray bottles containing liquid and labeled “Disinfectant.” One pacifier and one pacifier attached to a bib were also lying on top of the shelf. One of the caregivers stated that she knew the name of the child that the single pacifier belonged to but did not know the name of the child the pacifier attached to the bib belonged to. •The posted activity plan was dated August 11, 2025, through August 15, 2025. (Activity plans for the one-year-old children and three- and four-year-old children had the same dates, and a blank activity plan was posted for the school age children). •A posted attendance form was last completed on August 22, 2025. Parents sign children in and out of the facility on a tablet device in the lobby and Ms. Gaines and Ms. Williams-Mumford stated this is also used as the attendance for each classroom, but they prefer that staff also keep a written attendance in the classroom. •The one-year-old children (three in total) were moved from the infant children’s classroom to another classroom with a different caregiver during the visit. Prior to the children coming into the classroom, I monitored the room with Ms. Gaines. Ms. Gaines removed and locked up a bottle of “Play Day Bubble Blast Solution” for children ages three and up that was sitting on top of a child sized toy shelf. Warnings on the bottle included: Adult Supervision, Do Not Ingest, and In Case of Eye Contact Wash Out with Water. This classroom does not have a diaper changing area or sink. The staff member will have to take all the children back to the infant children’s classroom for diapering and handwashing and we discussed that the three children would not always need a diaper change at the same time. Ms. Gaines stated that none of these children had bottles. All children, but especially infants and young toddlers, are solely dependent on their caregivers for the completion of personal care routines (feeding, changing), interaction, and the assurance of a safe and healthy environment. Every responsibility when caring for these groups of children, is comprised when staff/child ratios are not in compliance, group size is exceeded, safe sleep checks are not completed, the safe sleep policy is not followed, and a safe and healthy environment is not maintained. I discussed my recommendation with Ms. Williams-Mumford that she contact Child Care Resource Center and speak with an Infant-Toddler Specialist and ask for a visit to the classroom to address these issues. We also discussed room arrangement and that the large, open, expansive classroom designated for the infant children could be divided by low shelves (like was observed during the pre-licensing visits) and the one-year-old children could be in a designated half of the classroom allowing their caregiver to have access to the diapering room and sinks. Ms. Gaines stated that they had ensured that a floater was always present to assist in all of classrooms as needed. Ms. Williams-Mumford stated that there had been unavoidable staff turnover as I stated that there was an obvious change in the last few weeks when attendance and safe sleep charts were not being completed. Ms. Williams-Mumford stated that she is affected by the staff shortage crisis and the quality and experience of persons who apply for positions. Diaper wipes in the hallway bathrooms were on the countertop and otherwise not stored at five vertical feet above the floor and had a Keep Out of Reach of Children warning label. As previously noted, activity plans for all groups of children were not current and/or posted for the past week. The playground had visible weeds inside the fenced in mulched play area, and along the fence line. A low hanging tree branch was hanging inside the play area. Ms. Williams-Mumford stated that these issues would be taken care of on Saturday when the lawn/landscape maintenance personnel came. She stated that they come every other week. I stated that the height and excessive growth of the weeds appeared to have not been addressed in the last two weeks. Your compliance history affects the star rating. It is imperative that all staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During today’s visit we again discussed the Rated License Assessment Process. On June 27, 2025, Ms. Williams-Mumford replied to an email I sent regarding the QRIS Modernization rules and processes, and she stated that she wished to proceed with the updated QRIS Modernization and would pursue Pathway 2. On August 24, 2025, I emailed her the most current Rated License Application, along with guideline for completing the requirements for Pathway 2 at each star level. Ms. Williams-Mumford will complete the application for a Star Rated License Assessment today and email it to me. You should also contact your local resource and referral agency for additional resources and technical assistance: Smart Start of Forsyth County 336-725-6011 https://smartstart-fc.org/ Education for staff will be assessed as part of the rated license. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the education rating for your staff members and for your rated license. Instructions for the DCDEE WORKS system is located on the DCDEE website at https://ncchildcare.ncdhhs.gov. Child Care Rules Chapter 9- Child Care Rules has been updated, effective July 1, 2025. Please review the rules and save a copy to your desktop or other file for quick reference. The Chapter 9- Child Care Rules can be found on the DCDEE website at https://ncchildcare.ncdhhs.gov, under the “Provider” tab in the home screen and selecting “Child Care Rules.” Health and Safety Training All staff must complete Health and Safety Trainings within one year of hire and must be repeated every five years with training certificates on file for review. These trainings can be accessed on the DCDEE website at https://ncchildcare.ncdhhs.gov under the Provider tab from the home screen, select Training and Professional Development, and finally DCDEE Moodle. If you need assistance in locating the trainings, please contact me. It is important to remember that the childcare administrator and all staff members must complete the specific Health and Safety Training called “Recognizing and Responding to Suspicions of Child Maltreatment”, within 90 days of employment. This training can be accessed through Moodle or directly at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. Orientation For New Staff/ New Staff Files/ CPR/FA and Trainings Health and safety training shall be in addition to the new staff orientation requirements. Orientation topics should be a review of the policies specific to your facility. All staff, including the director, must receive 16 hours of orientation. The orientation form is available on the DCDEE website www.ncchildcare.ncdhhs.gov under provider documents and forms. All documents listed on the staff file checklist must be in staff files and available for review. All CPR/FA training must be in-person by an approved training. Online CPR/FA courses will not be accepted. On-Going Professional Development. If staff complete approved college courses in child development, for every one college credit hour (CEU) completed staff will earn 16 hours of on-going training. All staff must complete the required number of on-going training hours based upon education and experience within one year of hire and annually. The required number of training hours can be determined for each staff member using the information provided in Child Care Rule 10A NCAC 09 .1103. Staff development trainings should include content on the following: Planning a safe, healthy learning environment Steps to advance children's physical and intellectual development Positive ways to support children's social and emotional Strategies to establish productive relationships with families Strategies to manage an effective program operation Maintaining a commitment to professionalism Observing and recording children's behavior Principles of child growth and development Learning activities that promote inclusion of children with special In addition to the required Health and Safety Trainings, staff can access professional development training on Moodle under Early Childhood Professional Development in the categories of Child Care and Development Fund (CCDF), Orientation and Regulatory. Updated training modules are being added, including a child care rule rollout with new rules effective July 1, 2025. An individual NCID username and password is needed to access DCDEE Moodle. If you experience problems with Moodle, contact dcdee_moodle_support@dhhs.nc.gov for assistance. For other training-related questions, please contact the Training and Program Development Consultant, Amia Eaton by calling (919) 814-6365 or emailing her at Amia.Eaton@dhhs.nc.gov. Specifically, under the Orientation section, I would encourage all staff to complete the training for “Child Development Module.” This training module provides a basic overview about child development and is designed to help early educators support infants, toddlers, and preschool children to reach their next developmental milestone. In addition to gaining introductory knowledge about child development, early educators will learn about the many resources and professional agencies available in North Carolina to help with promoting a responsive and engaging learning environment to support all children served. Upon completion, participants will receive one (1) contact hour credit (CHC). Staff Development Plan and Annual Evaluation All staff members must complete a Professional Development Plan and receive an annual evaluation within one year of hire. A sample staff development plan is available on the DCDEE website under Provider Documents and Forms. The Staff Development Plan and the annual evaluation are two different requirements. The purpose of the Staff Development Plan is to review staff goals and to see if these goals have been met, and to set new professional goals each year. The staff evaluation is to review each staff member’s job performance and to identify areas where the staff member is excelling and the areas where performance should be improved. For some areas for improvements that are of concern regarding the health and safety of children, a specific plan of action should be clearly outlined and show the plan will be monitored. I could not access the VPN or the Regulatory System to complete a computer-generated visit summary while at the facility. All observed violations and technical assistance were discussed with Ms. Gaines and Ms. Williams-Mumford during the visit. A handwritten visit summary was completed with Ms. Gaines, and a completed computer-generated visit summary will be emailed to her and Ms. Williams-Mumford following today’s visit. An email was sent to Ms. Williams-Mumford at 5:57pm explaining that I continued to have repeated issues with accessing the required systems and would email the visit summary as soon as possible. Ms. Williams-Mumford sent a reply email with the completed Rated License application and stated that she would be conducting a mandatory staff meeting tomorrow, August 29, 2025. This visit summary was completed and emailed to Ms. Gaines and Ms. Williams-Mumford on August 29, 2025. If you have any questions about the visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding the visit or any violations documented. 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: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 8/28/2025 Number Present: 21 Completed Date: 8/28/2025 Age: From 0 To 9 Total Minutes: 163 Time In: 10:42 AM Time Out: 01:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the second temporary time period visit. Upon my arrival, the visit was initiated with Melody Wheeler, staff member, and Nicole Gaines, Administrator, arrived at the facility within 20 minutes. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children aged zero to twelve-years-old and is approved to operate five classrooms within the building with a capacity of one hundred. Restrictions are daytime care only and no cooking allowed in building. The Secretary of State website was checked today, and the owner, the Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. During the visit there were three classrooms in operation and children aged zero to nine-years-old were in care. A fourth classroom was opened during the visit and staff moved the one-year-old children into this space for care so that staff/child ratios were in compliance for the infant children present today. All designated indoor and outdoor spaces for childcare were monitored today. All staff files, a percentage of children’s files and program records will be monitored during a follow-up visit. All documents required to be posted were observed in the center lobby. The facility does not provide transportation. There were no observed changes to the playground area since the pre-licensing and first temporary period visits. Ms. Williams-Mumford provided information today during a telephone call with me while I was on-site, that the school age children present today are attending private school at the facility. She stated that the private school is registered as The Leading Legacy Academy. These children are also enrolled in childcare. The private school operates from 8:00a.m. to 1:30p.m. and the children are then in the licensed childcare program. Pre-packaged breakfast items and snacks are provided to children by the facility and lunch meals are catered by J. Butlers restaurant. During today’s visit children present were observed to be engaged in group and free choice activities, personal care routines, outdoor play, lunch, and nap. The lunch served was chicken tenders, mashed potatoes, mixed vegetables (peas and carrots) and milk. The following violations were cited during today’s visit: Violation Number Comment Rule 205 Storage space was not available for each child's personal belongings. A storage cube, identified by staff, as an enrolled child's personal storage space contained items not belonging to the child such as "Lysol Brand New Day" Disinfecting Wipes, two plastic unlabeled sandwich baggies containing crackers and cookies that belonged to a staff member, a lanyard with attached pepper spray that belonged to a staff member, other children's clothing and shoes, a magnetic key lock for one of the cabinets in the diapering or food prep rooms, unlabeled pacifiers, a container of Gerber Baby Food Blueberry Puffs that staff stated were for all children in the classroom, a package of "Boogie Wipes" not labeled with a child's name, and a sippy cup filled with clear liquid with a different child's name on the cup. G.S. 110-91(6) 301 Minimum staff/child ratios and group sizes for the number and ages of children in care were not met. Twelve children ages zero to one-years-old were in combined care in Space 1 A/B with two staff members. GS 110-91(7);.0713(a-d) 303 Children were not adequately supervised at all times. One-year-old children in care in Space 1 A/B were observed walking alone into the food preparation area, walking out the classroom door, which was open, into the hallway alone, pulling other children's hair, and playing over and lying on an infant that was engaged in tummy time. The inside of the infant cribs could not be seen by staff in the main caregiving area due to crib placement in the classroom. .1801(a)(1-5) 428 A current activity plan was not posted for each group of children for reference. Activity plans posted in classrooms where children ages zero to four-years-old were in care were dated August 11, 2025 through August 15, 2025. A blank activity plan was posted in the classroom where school age children are in care. GS 110-91(12); .0508(a) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Eight bottles for three infants in care in Space 1 A/B were not dated. Three additional bottles for two other infants in care in the same space were not labeled or dated. 15A NCAC 18A .2804(d) 808 The child care center premises, including the outdoor learning environment, was not clean, drained to minimize standing water, free of litter and hazards, and/or maintained in a manner which does not create conditions that attract or harbor pests. Weeds were growing inside the fenced-in mulched play area and along the fence line. A low hanging tree branch was hanging into the play area. 15A NCAC 18A .2832(a) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A bottle of foaming hand sanitizer, a box of Ziplock Gallon size Storage Bags, and a package of Parent's Choice Diaper Wipes, all with Keep Out of Reach of Children warnings, were placed on a low shelf and accessible to children in Space 1 A/B. Parents Choice Diaper Wipes were on the countertop of the hallway bathroom used by children. .0604(a) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. A staff members personal lanyard with keys had an attached button pouch containing pepper spray and was stored inside an enrolled child's storage cube sitting on a low, accessible to children, storage shelf. A container of "Lysol Brand New Day" disinfecting wipes were also stored in the child's storage cube. Also on top of the same low shelf were two spray bottles that were labeled and contained Disinfectant. .2820(b) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. A tube of Boudreaux's Butt Paste diaper cream and a tube of Baby Organics sunscreen were in a storage cube sitting on a low shelf and were not made inaccessible to children according to the requirements of Sanitation Rule 15A NCAC 18A .2820(d). 15A NCAC 18A .2820(d) 871 Center staff did not comply with the safe sleep policy. An infant in care in Space 1 A/B was observed asleep in a swing and covered by a blanket at collarbone level. 10A NCAC 09 .0606(a) 887 Caregivers did not document compliance with visually checking on sleeping infants aged 12 months or younger and/or the documents were not maintained for a minimum of one month. Safe sleep charts documenting staff members visual checks of sleeping infants had not been completed for a period of one to two weeks while enrolled infants were in care in Space 1 A/B. .0606(g) All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by September 11, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov using the same format we have already reviewed. Technical Assistance and/or Consultation were provided during today’s visit on the following: Violations in the infant children’s classroom and food prep area were discussed with the assigned caregivers, Ms. Wheeler and Ms. Gaines and were also reviewed by telephone with Ms. Williams-Mumford during the visit: •There were 9 infants in care today. Safe sleep check forms were observed for 10 enrolled infants, and the last documented safe sleep checks are as follows: Child 1 last documented 8/7/25 (Ms. Gaines and Ms. Williams-Mumford stated this child had been absent from care for a few weeks). Child 2 last documented 8/18/25 Child 3 last documented 8/20/25 Child 4 last documented 8/20/25 Child 5 last documented 8/21/25 Child 6 last documented 8/21/25 Child 7 last documented 8/21/25 Child 8 last documented 8/21/25 Child 9 last documented 8/21/25 Child 10 last documented 8/22/25 Staff members’ names and initials on the Safe Sleep Check forms that had been completed were not the assigned caregivers during today’s visit. When staff members caring for infant children today were asked about safe sleep check forms for today, one of the staff members stated none of the infants had been asleep today. One infant was observed to be asleep in a swing with a blanket placed on the child at collarbone level. One of the assigned caregivers was the parent of this child. When asked both caregivers state they had completed ITS-SIDS training and one of the caregivers stated she had previous work experience in licensed child care, but not as an infant caregiver. •The nine infants in care were grouped with three children who were one year old. A total of twelve children were in care in the space with two caregivers. The applicable staff/child ratio form was posted in the classroom showing a staff ratio for children ages 0-12 months old as 1 staff person for every five children and a maximum group size of 10 children. The box for Enhanced Requirements was checked on the form. One staff member went to prepare a bottle in the food prep area (not visible from the classroom) leaving one staff member with 11 children on more than one occasion during the visit. The three children who are one year old were mobile and active, walking around the classroom, into the food preparation area, out the classroom door, which was open, into the hallway, pulling hair, and playing over and lying on an infant that was engaged in tummy time. I explained to the caregivers that staff/child ratio was not in compliance and brought the children’s behavior to their attention as it occurred. One of the assigned caregivers stated that they had decided to group the children today. •One infant was asleep in a swing with a blanket on the child for more than 20 minutes. This infant was the child of one of the assigned caregivers. After I verbally brought this to the attention of the staff, the child was removed from the swing, and the blanket was removed. The safe sleep policy was posted in the classroom, noting that infants are not placed in safety seats, strollers, swings, or infant carriers to sleep, that approved sleeping devices (CPSC) are used, and that objects such as pillows, blankets, or toys in the crib or sleep space are not allowed. •Cribs were observed to be placed away from the primary caregiving area in the classroom and were not arranged in a manner that would allow appropriate supervision. •Eight bottles for three of the infants present were not dated. Three additional bottles were not labeled or dated. These three bottles were for infants belonging to one of the assigned caregivers. There were labels and a Sharpie marker on a tabletop shelf in the food prep area. One of the assigned caregivers stated during morning drop-off that the parent of one of the children stated he had not dated the bottles, and she had forgotten to date the bottles. •The mini refrigerator in the food prep room containing the infant's bottles had a stem thermometer at the bottom of the refrigerator that read 160 degrees. One bottle that was stored on its side at the bottom of the refrigerator had leaked formula into the bottom of the refrigerator. The stem thermometer was replaced with a digital thermometer by Ms. Gaines during the visit. Ms. Wheeler also cleaned up the spilled formula. •Collapsible cube organizers inside a low storage shelf are used to store the belongings for each of the enrolled infants. One’s enrolled infant’s cube (child identified by staff) was sitting on top of the shelf that could be easily accessed by some of the mobile children and contained the following items: A container of Lysol “Brand New Day” disinfecting wipes A tube of Boudreaux’s Butt Paste with “EC” written on the tube A tube of Baby Organics sunscreen with “EC” written on the tube Two Pacifiers not labeled Boy’s clothes, shoes and underwear Girl’s clothing and shoes An unlabeled sandwich baggie of cheddar crackers shaped like turtles An unlabeled sandwich baggie of teddy bears shaped cookies An unlabeled container of Gerber Baby Food Blueberry Puffs (puffed grain snack) A sippy cup of what appeared to be water labeled with a child’s name (not the child for this assigned cube) A package of “Boogie Wipes” Gentle Saline Nose Wipes not labeled with a child's name A magnetic cabinet door lock that staff stated was for a cabinet in the diapering or food prep rooms A lanyard with keys with an attached button pouch containing a cylinder of pepper spray One of the assigned caregivers stated that the crackers and cookies belonged to her, the Gerber puff snacks were for all the children, and the keys belonged to the other assigned caregiver. This caregiver stated that when they clean up the room, everything was usually thrown into this cube. This staff member removed the keys with the pepper spray pouch, acknowledging that these should be locked up, and took them to the food prep room and hung them on a wall hook. The cube was also taken into the room and placed on the floor. The food prep room was not locked, the door was open, and two of the one-year-old children were walking in and out of the room. Ms. Gaines placed all of the items, including the staff member’s keys, in a locked storage closet that is inside the food prep room. When Ms. Gaines and I returned later to the food prep room to check the temperature of the refrigerator on the digital thermometer she had placed in the refrigerator, the storage door was unlocked and partially open. Ms. Gaines closed and locked the door again. •Above the low shelf (lower than five feet) with cubicles for the children’s belongings was a wall mounted dry erase board where staff wrote information about children’s feedings and diapering. On top of the shelf and accessible to the children was a package of Parent’s Choice Diaper Wipes which was labeled Keep Out of Reach of Children. I observed one of the staff members wipe off the dry erase board with one of the wipes and lay the used wipe down on top of the package of wipes. The shelf also had a bottle of foaming hand sanitizer labeled Keep Out of Reach of Children, a box of Ziplock Gallon Storage bags labeled To Avoid Suffocation Keep Out of Reach of Children, and two clear spray bottles containing liquid and labeled “Disinfectant.” One pacifier and one pacifier attached to a bib were also lying on top of the shelf. One of the caregivers stated that she knew the name of the child that the single pacifier belonged to but did not know the name of the child the pacifier attached to the bib belonged to. •The posted activity plan was dated August 11, 2025, through August 15, 2025. (Activity plans for the one-year-old children and three- and four-year-old children had the same dates, and a blank activity plan was posted for the school age children). •A posted attendance form was last completed on August 22, 2025. Parents sign children in and out of the facility on a tablet device in the lobby and Ms. Gaines and Ms. Williams-Mumford stated this is also used as the attendance for each classroom, but they prefer that staff also keep a written attendance in the classroom. •The one-year-old children (three in total) were moved from the infant children’s classroom to another classroom with a different caregiver during the visit. Prior to the children coming into the classroom, I monitored the room with Ms. Gaines. Ms. Gaines removed and locked up a bottle of “Play Day Bubble Blast Solution” for children ages three and up that was sitting on top of a child sized toy shelf. Warnings on the bottle included: Adult Supervision, Do Not Ingest, and In Case of Eye Contact Wash Out with Water. This classroom does not have a diaper changing area or sink. The staff member will have to take all the children back to the infant children’s classroom for diapering and handwashing and we discussed that the three children would not always need a diaper change at the same time. Ms. Gaines stated that none of these children had bottles. All children, but especially infants and young toddlers, are solely dependent on their caregivers for the completion of personal care routines (feeding, changing), interaction, and the assurance of a safe and healthy environment. Every responsibility when caring for these groups of children, is comprised when staff/child ratios are not in compliance, group size is exceeded, safe sleep checks are not completed, the safe sleep policy is not followed, and a safe and healthy environment is not maintained. I discussed my recommendation with Ms. Williams-Mumford that she contact Child Care Resource Center and speak with an Infant-Toddler Specialist and ask for a visit to the classroom to address these issues. We also discussed room arrangement and that the large, open, expansive classroom designated for the infant children could be divided by low shelves (like was observed during the pre-licensing visits) and the one-year-old children could be in a designated half of the classroom allowing their caregiver to have access to the diapering room and sinks. Ms. Gaines stated that they had ensured that a floater was always present to assist in all of classrooms as needed. Ms. Williams-Mumford stated that there had been unavoidable staff turnover as I stated that there was an obvious change in the last few weeks when attendance and safe sleep charts were not being completed. Ms. Williams-Mumford stated that she is affected by the staff shortage crisis and the quality and experience of persons who apply for positions. Diaper wipes in the hallway bathrooms were on the countertop and otherwise not stored at five vertical feet above the floor and had a Keep Out of Reach of Children warning label. As previously noted, activity plans for all groups of children were not current and/or posted for the past week. The playground had visible weeds inside the fenced in mulched play area, and along the fence line. A low hanging tree branch was hanging inside the play area. Ms. Williams-Mumford stated that these issues would be taken care of on Saturday when the lawn/landscape maintenance personnel came. She stated that they come every other week. I stated that the height and excessive growth of the weeds appeared to have not been addressed in the last two weeks. Your compliance history affects the star rating. It is imperative that all staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During today’s visit we again discussed the Rated License Assessment Process. On June 27, 2025, Ms. Williams-Mumford replied to an email I sent regarding the QRIS Modernization rules and processes, and she stated that she wished to proceed with the updated QRIS Modernization and would pursue Pathway 2. On August 24, 2025, I emailed her the most current Rated License Application, along with guideline for completing the requirements for Pathway 2 at each star level. Ms. Williams-Mumford will complete the application for a Star Rated License Assessment today and email it to me. You should also contact your local resource and referral agency for additional resources and technical assistance: Smart Start of Forsyth County 336-725-6011 https://smartstart-fc.org/ Education for staff will be assessed as part of the rated license. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the education rating for your staff members and for your rated license. Instructions for the DCDEE WORKS system is located on the DCDEE website at https://ncchildcare.ncdhhs.gov. Child Care Rules Chapter 9- Child Care Rules has been updated, effective July 1, 2025. Please review the rules and save a copy to your desktop or other file for quick reference. The Chapter 9- Child Care Rules can be found on the DCDEE website at https://ncchildcare.ncdhhs.gov, under the “Provider” tab in the home screen and selecting “Child Care Rules.” Health and Safety Training All staff must complete Health and Safety Trainings within one year of hire and must be repeated every five years with training certificates on file for review. These trainings can be accessed on the DCDEE website at https://ncchildcare.ncdhhs.gov under the Provider tab from the home screen, select Training and Professional Development, and finally DCDEE Moodle. If you need assistance in locating the trainings, please contact me. It is important to remember that the childcare administrator and all staff members must complete the specific Health and Safety Training called “Recognizing and Responding to Suspicions of Child Maltreatment”, within 90 days of employment. This training can be accessed through Moodle or directly at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. Orientation For New Staff/ New Staff Files/ CPR/FA and Trainings Health and safety training shall be in addition to the new staff orientation requirements. Orientation topics should be a review of the policies specific to your facility. All staff, including the director, must receive 16 hours of orientation. The orientation form is available on the DCDEE website www.ncchildcare.ncdhhs.gov under provider documents and forms. All documents listed on the staff file checklist must be in staff files and available for review. All CPR/FA training must be in-person by an approved training. Online CPR/FA courses will not be accepted. On-Going Professional Development. If staff complete approved college courses in child development, for every one college credit hour (CEU) completed staff will earn 16 hours of on-going training. All staff must complete the required number of on-going training hours based upon education and experience within one year of hire and annually. The required number of training hours can be determined for each staff member using the information provided in Child Care Rule 10A NCAC 09 .1103. Staff development trainings should include content on the following: Planning a safe, healthy learning environment Steps to advance children's physical and intellectual development Positive ways to support children's social and emotional Strategies to establish productive relationships with families Strategies to manage an effective program operation Maintaining a commitment to professionalism Observing and recording children's behavior Principles of child growth and development Learning activities that promote inclusion of children with special In addition to the required Health and Safety Trainings, staff can access professional development training on Moodle under Early Childhood Professional Development in the categories of Child Care and Development Fund (CCDF), Orientation and Regulatory. Updated training modules are being added, including a child care rule rollout with new rules effective July 1, 2025. An individual NCID username and password is needed to access DCDEE Moodle. If you experience problems with Moodle, contact dcdee_moodle_support@dhhs.nc.gov for assistance. For other training-related questions, please contact the Training and Program Development Consultant, Amia Eaton by calling (919) 814-6365 or emailing her at Amia.Eaton@dhhs.nc.gov. Specifically, under the Orientation section, I would encourage all staff to complete the training for “Child Development Module.” This training module provides a basic overview about child development and is designed to help early educators support infants, toddlers, and preschool children to reach their next developmental milestone. In addition to gaining introductory knowledge about child development, early educators will learn about the many resources and professional agencies available in North Carolina to help with promoting a responsive and engaging learning environment to support all children served. Upon completion, participants will receive one (1) contact hour credit (CHC). Staff Development Plan and Annual Evaluation All staff members must complete a Professional Development Plan and receive an annual evaluation within one year of hire. A sample staff development plan is available on the DCDEE website under Provider Documents and Forms. The Staff Development Plan and the annual evaluation are two different requirements. The purpose of the Staff Development Plan is to review staff goals and to see if these goals have been met, and to set new professional goals each year. The staff evaluation is to review each staff member’s job performance and to identify areas where the staff member is excelling and the areas where performance should be improved. For some areas for improvements that are of concern regarding the health and safety of children, a specific plan of action should be clearly outlined and show the plan will be monitored. I could not access the VPN or the Regulatory System to complete a computer-generated visit summary while at the facility. All observed violations and technical assistance were discussed with Ms. Gaines and Ms. Williams-Mumford during the visit. A handwritten visit summary was completed with Ms. Gaines, and a completed computer-generated visit summary will be emailed to her and Ms. Williams-Mumford following today’s visit. An email was sent to Ms. Williams-Mumford at 5:57pm explaining that I continued to have repeated issues with accessing the required systems and would email the visit summary as soon as possible. Ms. Williams-Mumford sent a reply email with the completed Rated License application and stated that she would be conducting a mandatory staff meeting tomorrow, August 29, 2025. This visit summary was completed and emailed to Ms. Gaines and Ms. Williams-Mumford on August 29, 2025. If you have any questions about the visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding the visit or any violations documented. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0901 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 5 Completed Date: 7/2/2025 Age: From 0 To 3 Total Minutes: 187 Time In: 11:38 AM Time Out: 02:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the first temporary time visit. The visit was conducted with Alexis Washington, Assistant Director. Keeyama-Williams Mumford, Owner, and Nicole Gaines, Administrator, arrived during the visit. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children ages zero to twelve-years-old and is approved to operate five classrooms within the building. Restrictions are daytime care only and no cooking allowed in the building. All classrooms have direct exits. The Secretary of State website was reviewed, and the owner, The Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. There are currently two classrooms in operation with children aged from infants to three-years-old in care and both classrooms were monitored during today’s visit. All program records, documents required to be posted, and a sampling of staff and children’s files were monitored. There are three outdoor playgrounds designated for infants/toddlers, three/ four/five-year-olds, and school age which were monitored today. The playgrounds are surfaced with, concrete and mulch and grass. There are no stationary pieces of equipment requiring mulch in fall zones. The playgrounds are enclosed by metal fencing which exceeds four feet in height. The facility does not provide transportation. Pre-packaged snacks/breakfast are provided by the facility and lunch is catered in by J. Butlers restaurant. The facility is equipped with a warming kitchen. During today’s visit, children present were observed to be engaged in personal care routines, lunch, and nap. Children were served chicken tenders, macaroni and cheese, and milk and water for lunch. The posted menu stated that fish sticks, carrots, pineapples and milk were to be served. The following violations were cited during today’s visit: Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in the classrooms for one infant and four children ages two to three years old. GS 110-91(12); .0508(a) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Children's lunch served today, chicken tenders and macaroni and cheese, did not include the required components to meet meal pattern requirements. 10A NCAC 09 .0901(a) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. The posted lunch menu documented fish sticks, carrots, pineapple and milk for lunch. Children were served chicken tenders, macaroni and cheese, milk and water. 10A NCAC 09 .0901(b) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Bottles for an infant in care today were not dated. 15A NCAC 18A .2804(d) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator in the infant food prep area did not have a thermometer. 15A NCAC 18A .2806(j)(2) 1757 A valid qualification letter was not on file and available to review at the facility. Two staff members did not have a copy of their Criminal Background Qualification Letters on file. The letters were on the phones of staff and administrators, but not in their staff file. G.S. 110-90.2(b) & (d) & .2703(e) 1831 At least one child care provider, who has completed ITS-SIDS training was not present in the infant room, while children were in care. The infant caregiver, the only staff member in the infant classroom, did not have ITS-SIDS training certification on file. .01102 (f) 1914 The person identified as the person or alternate person responsible for carrying out the emergency medical care plan was not on the premises at all times and/or did not accompany children for off premise activities. The assistant director was the only administrative staff on-site with staff. The emergency medical plan only lists the owner and director's names. .0802(b)(1-2) Technical Assistance Provided During Today’s Visit: The center’s Emergency Medical Care Plan listed the names of the owner and administrator, who were not on site initially at the time of the visit. Both had left the facility, and the assistant director was not named on the plan. Everyone needs to be aware of who was designated in what roles an emergency should occur. If parents do not date an infant’s bottles daily, please ask staff to date the bottles. Ms. Williams-Mumford showed me labels that she has for the purpose of dating and labeling bottles if parents forget. Each day the infant teacher should make sure the thermometer is in the refrigerator. Activity Plans must be completed and posted for each age group of children in care and for each individual infant. Caregivers should have a current plan ready for each week/month and ensure that the current plan is posted when they open the classrooms each day. Any substitutions must immediately be noted on the menu posted and all food served must meet the USDA Meal Pattern requirements for all aged children in care. Today’s lunch and meals did not include vegetables. Ms. Williams-Mumford will contact the manager of the restaurant who caters food for the children’s meals and discuss why they sent food substitutions and why the meal did not contain the required components. The infant caregiver has stated that she has completed ITS-SIDS training. However, there is no training certificate on file, so the training cannot be confirmed. The staff member is scheduled to again complete the training on July 15, 2025. An individual who has completed ITS-SIDS training and has a valid certificate on file must be in the infant classroom at all times. Criminal background Check Qualification Letters were not on file for two staff members. You may consider requiring potential employees to submit this letter with their application, so that a hard copy will be on file if they hired. All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by July 16, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov. Include in the documentation the following: 1. Name of your facility and ID# 2. Date of the Visit 3. Date of the Documentation you are submitting 4. Each Item Number of the Violations Cited 5. Date of when each item number was corrected 6. How the item was corrected 7. Signature of the person submitting the documentation Your compliance history affects the star rating. It is imperative that staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During the Pre-Licensing Visits conducted on May 21, 2025, and May 27, 2025, I discussed the process for rated license assessments as well as possible upcoming rule changes related to the Quality Rating and Improvement System (QRIS) Modernization, which were currently not in rule at the time of that visit with the owner of the facility. Resources including Smart Start of Forsyth County and the North Carolina Rated License Assessment Project website were also provided. An application for a Rated License Assessment, a Request for an Environment Rating Scale Assessment and a Quality Point option form were provided to you during today’s visit. On June 27, 2025, Ms. Williams-Mumford, owner, sent an email reply to me stating that she would like to be assessed for the final star rated license under the new child care rules and procedures with QRIS Modernization. Please submit by email the Rated License application and the Request for the Environment Rating Scale Assessment (if applicable) to me no later than August 1, 2025. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the points in education for your license. Instructions for the DCDEE WORKS system is located in the DCDEE website at https://ncchildcare.ncdhhs.gov. Register with Department of Justice You must register with the Department of Justice to receive e-mail or phone call notification if a sex offender moves into your area. To register, call 1-877-627-2826 or you may register on line at: http://sexoffender.ncdoj.gov/. To reference the law concerning Sex offender and Public Protection Registration Programs you may go to: http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_14/Article_27A.html. Contact the local Sheriff's Department if a sex offender email or phone notification is received from the NC Sex Offender Registry. Emergency Preparedness and Response Plan Emergency Preparedness and Response Training has been completed and you must complete an EPR Plan on a template at the following website https://rmp.nc.gov/portal/portal.aspx within four (4) months. A copy of the EPR plan must be printed and on file at the facility for review. After you complete the Emergency Preparedness and Response in Child Care training, you must conduct either a shelter-in-place or a lockdown drill every three months. Use the Emergency Drill Log to document these additional drills as well as the fire drills. The form is located under the Provider Documents tab on the DCDEE website at www.ncchildcare.ncdhhs.gov. The EPR Plan will be reviewed with all staff upon hire during orientation, whenever changes to the plan occur, and at least yearly. The date of the review of the plan with staff should be documented on the Staff and Training Worksheets. In addition, the administrator must review the plan annually in the portal and make updates if required. Once reviewed, print off the first page of the plan which will reflect the date of the review. A visit summary was prepared and a copy provided to Ms. Washington during the visit. If you have any further questions about today’s visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding today’s visit or any violations documented. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

G.S. 110-90 · Violation

Name of Operation: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 5 Completed Date: 7/2/2025 Age: From 0 To 3 Total Minutes: 187 Time In: 11:38 AM Time Out: 02:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the first temporary time visit. The visit was conducted with Alexis Washington, Assistant Director. Keeyama-Williams Mumford, Owner, and Nicole Gaines, Administrator, arrived during the visit. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children ages zero to twelve-years-old and is approved to operate five classrooms within the building. Restrictions are daytime care only and no cooking allowed in the building. All classrooms have direct exits. The Secretary of State website was reviewed, and the owner, The Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. There are currently two classrooms in operation with children aged from infants to three-years-old in care and both classrooms were monitored during today’s visit. All program records, documents required to be posted, and a sampling of staff and children’s files were monitored. There are three outdoor playgrounds designated for infants/toddlers, three/ four/five-year-olds, and school age which were monitored today. The playgrounds are surfaced with, concrete and mulch and grass. There are no stationary pieces of equipment requiring mulch in fall zones. The playgrounds are enclosed by metal fencing which exceeds four feet in height. The facility does not provide transportation. Pre-packaged snacks/breakfast are provided by the facility and lunch is catered in by J. Butlers restaurant. The facility is equipped with a warming kitchen. During today’s visit, children present were observed to be engaged in personal care routines, lunch, and nap. Children were served chicken tenders, macaroni and cheese, and milk and water for lunch. The posted menu stated that fish sticks, carrots, pineapples and milk were to be served. The following violations were cited during today’s visit: Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in the classrooms for one infant and four children ages two to three years old. GS 110-91(12); .0508(a) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Children's lunch served today, chicken tenders and macaroni and cheese, did not include the required components to meet meal pattern requirements. 10A NCAC 09 .0901(a) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. The posted lunch menu documented fish sticks, carrots, pineapple and milk for lunch. Children were served chicken tenders, macaroni and cheese, milk and water. 10A NCAC 09 .0901(b) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Bottles for an infant in care today were not dated. 15A NCAC 18A .2804(d) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator in the infant food prep area did not have a thermometer. 15A NCAC 18A .2806(j)(2) 1757 A valid qualification letter was not on file and available to review at the facility. Two staff members did not have a copy of their Criminal Background Qualification Letters on file. The letters were on the phones of staff and administrators, but not in their staff file. G.S. 110-90.2(b) & (d) & .2703(e) 1831 At least one child care provider, who has completed ITS-SIDS training was not present in the infant room, while children were in care. The infant caregiver, the only staff member in the infant classroom, did not have ITS-SIDS training certification on file. .01102 (f) 1914 The person identified as the person or alternate person responsible for carrying out the emergency medical care plan was not on the premises at all times and/or did not accompany children for off premise activities. The assistant director was the only administrative staff on-site with staff. The emergency medical plan only lists the owner and director's names. .0802(b)(1-2) Technical Assistance Provided During Today’s Visit: The center’s Emergency Medical Care Plan listed the names of the owner and administrator, who were not on site initially at the time of the visit. Both had left the facility, and the assistant director was not named on the plan. Everyone needs to be aware of who was designated in what roles an emergency should occur. If parents do not date an infant’s bottles daily, please ask staff to date the bottles. Ms. Williams-Mumford showed me labels that she has for the purpose of dating and labeling bottles if parents forget. Each day the infant teacher should make sure the thermometer is in the refrigerator. Activity Plans must be completed and posted for each age group of children in care and for each individual infant. Caregivers should have a current plan ready for each week/month and ensure that the current plan is posted when they open the classrooms each day. Any substitutions must immediately be noted on the menu posted and all food served must meet the USDA Meal Pattern requirements for all aged children in care. Today’s lunch and meals did not include vegetables. Ms. Williams-Mumford will contact the manager of the restaurant who caters food for the children’s meals and discuss why they sent food substitutions and why the meal did not contain the required components. The infant caregiver has stated that she has completed ITS-SIDS training. However, there is no training certificate on file, so the training cannot be confirmed. The staff member is scheduled to again complete the training on July 15, 2025. An individual who has completed ITS-SIDS training and has a valid certificate on file must be in the infant classroom at all times. Criminal background Check Qualification Letters were not on file for two staff members. You may consider requiring potential employees to submit this letter with their application, so that a hard copy will be on file if they hired. All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by July 16, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov. Include in the documentation the following: 1. Name of your facility and ID# 2. Date of the Visit 3. Date of the Documentation you are submitting 4. Each Item Number of the Violations Cited 5. Date of when each item number was corrected 6. How the item was corrected 7. Signature of the person submitting the documentation Your compliance history affects the star rating. It is imperative that staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During the Pre-Licensing Visits conducted on May 21, 2025, and May 27, 2025, I discussed the process for rated license assessments as well as possible upcoming rule changes related to the Quality Rating and Improvement System (QRIS) Modernization, which were currently not in rule at the time of that visit with the owner of the facility. Resources including Smart Start of Forsyth County and the North Carolina Rated License Assessment Project website were also provided. An application for a Rated License Assessment, a Request for an Environment Rating Scale Assessment and a Quality Point option form were provided to you during today’s visit. On June 27, 2025, Ms. Williams-Mumford, owner, sent an email reply to me stating that she would like to be assessed for the final star rated license under the new child care rules and procedures with QRIS Modernization. Please submit by email the Rated License application and the Request for the Environment Rating Scale Assessment (if applicable) to me no later than August 1, 2025. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the points in education for your license. Instructions for the DCDEE WORKS system is located in the DCDEE website at https://ncchildcare.ncdhhs.gov. Register with Department of Justice You must register with the Department of Justice to receive e-mail or phone call notification if a sex offender moves into your area. To register, call 1-877-627-2826 or you may register on line at: http://sexoffender.ncdoj.gov/. To reference the law concerning Sex offender and Public Protection Registration Programs you may go to: http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_14/Article_27A.html. Contact the local Sheriff's Department if a sex offender email or phone notification is received from the NC Sex Offender Registry. Emergency Preparedness and Response Plan Emergency Preparedness and Response Training has been completed and you must complete an EPR Plan on a template at the following website https://rmp.nc.gov/portal/portal.aspx within four (4) months. A copy of the EPR plan must be printed and on file at the facility for review. After you complete the Emergency Preparedness and Response in Child Care training, you must conduct either a shelter-in-place or a lockdown drill every three months. Use the Emergency Drill Log to document these additional drills as well as the fire drills. The form is located under the Provider Documents tab on the DCDEE website at www.ncchildcare.ncdhhs.gov. The EPR Plan will be reviewed with all staff upon hire during orientation, whenever changes to the plan occur, and at least yearly. The date of the review of the plan with staff should be documented on the Staff and Training Worksheets. In addition, the administrator must review the plan annually in the portal and make updates if required. Once reviewed, print off the first page of the plan which will reflect the date of the review. A visit summary was prepared and a copy provided to Ms. Washington during the visit. If you have any further questions about today’s visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding today’s visit or any violations documented. 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: The Leading Legacy Academy Facility ID: 34001443 Consultant: TAMMY CHILDRESS Operation Type: Center Case Number: Visit Date: 7/2/2025 Number Present: 5 Completed Date: 7/2/2025 Age: From 0 To 3 Total Minutes: 187 Time In: 11:38 AM Time Out: 02:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Temp Time Period Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance with all applicable child care requirements during the first temporary time visit. The visit was conducted with Alexis Washington, Assistant Director. Keeyama-Williams Mumford, Owner, and Nicole Gaines, Administrator, arrived during the visit. Currently this center operates with a Temporary License, issued on May 27, 2025, to operate first shift. The facility is licensed to provide care for children ages zero to twelve-years-old and is approved to operate five classrooms within the building. Restrictions are daytime care only and no cooking allowed in the building. All classrooms have direct exits. The Secretary of State website was reviewed, and the owner, The Leading Legacy Academy, LLC, is current on all required documents and active on the NC Business Registry. If any changes to the corporation need to be made or you decide to sale your business, then you must notify your consultant at least thirty days prior to any changes occurring. The license cannot be bought, sold, subleased, transferred to another person or location, or inherited. There are currently two classrooms in operation with children aged from infants to three-years-old in care and both classrooms were monitored during today’s visit. All program records, documents required to be posted, and a sampling of staff and children’s files were monitored. There are three outdoor playgrounds designated for infants/toddlers, three/ four/five-year-olds, and school age which were monitored today. The playgrounds are surfaced with, concrete and mulch and grass. There are no stationary pieces of equipment requiring mulch in fall zones. The playgrounds are enclosed by metal fencing which exceeds four feet in height. The facility does not provide transportation. Pre-packaged snacks/breakfast are provided by the facility and lunch is catered in by J. Butlers restaurant. The facility is equipped with a warming kitchen. During today’s visit, children present were observed to be engaged in personal care routines, lunch, and nap. Children were served chicken tenders, macaroni and cheese, and milk and water for lunch. The posted menu stated that fish sticks, carrots, pineapples and milk were to be served. The following violations were cited during today’s visit: Violation Number Comment Rule 428 A current activity plan was not posted for each group of children for reference. An activity plan was not posted in the classrooms for one infant and four children ages two to three years old. GS 110-91(12); .0508(a) 501 Meals/snacks did not comply with the Meal Patterns for Children in Child Care Programs. Children's lunch served today, chicken tenders and macaroni and cheese, did not include the required components to meet meal pattern requirements. 10A NCAC 09 .0901(a) 528 Food substitution was not of comparable food value or recorded on the menu prior to the meal or snack being served. The posted lunch menu documented fish sticks, carrots, pineapple and milk for lunch. Children were served chicken tenders, macaroni and cheese, milk and water. 10A NCAC 09 .0901(b) 533 Human milk, formula and other bottled beverages including sippy cups, sent from child's home were not fully prepared, dated, and labeled for the appropriate child. Bottles for an infant in care today were not dated. 15A NCAC 18A .2804(d) 601 Refrigerator(s) did not maintain a temperature of 45 degrees F. or below. The refrigerator in the infant food prep area did not have a thermometer. 15A NCAC 18A .2806(j)(2) 1757 A valid qualification letter was not on file and available to review at the facility. Two staff members did not have a copy of their Criminal Background Qualification Letters on file. The letters were on the phones of staff and administrators, but not in their staff file. G.S. 110-90.2(b) & (d) & .2703(e) 1831 At least one child care provider, who has completed ITS-SIDS training was not present in the infant room, while children were in care. The infant caregiver, the only staff member in the infant classroom, did not have ITS-SIDS training certification on file. .01102 (f) 1914 The person identified as the person or alternate person responsible for carrying out the emergency medical care plan was not on the premises at all times and/or did not accompany children for off premise activities. The assistant director was the only administrative staff on-site with staff. The emergency medical plan only lists the owner and director's names. .0802(b)(1-2) Technical Assistance Provided During Today’s Visit: The center’s Emergency Medical Care Plan listed the names of the owner and administrator, who were not on site initially at the time of the visit. Both had left the facility, and the assistant director was not named on the plan. Everyone needs to be aware of who was designated in what roles an emergency should occur. If parents do not date an infant’s bottles daily, please ask staff to date the bottles. Ms. Williams-Mumford showed me labels that she has for the purpose of dating and labeling bottles if parents forget. Each day the infant teacher should make sure the thermometer is in the refrigerator. Activity Plans must be completed and posted for each age group of children in care and for each individual infant. Caregivers should have a current plan ready for each week/month and ensure that the current plan is posted when they open the classrooms each day. Any substitutions must immediately be noted on the menu posted and all food served must meet the USDA Meal Pattern requirements for all aged children in care. Today’s lunch and meals did not include vegetables. Ms. Williams-Mumford will contact the manager of the restaurant who caters food for the children’s meals and discuss why they sent food substitutions and why the meal did not contain the required components. The infant caregiver has stated that she has completed ITS-SIDS training. However, there is no training certificate on file, so the training cannot be confirmed. The staff member is scheduled to again complete the training on July 15, 2025. An individual who has completed ITS-SIDS training and has a valid certificate on file must be in the infant classroom at all times. Criminal background Check Qualification Letters were not on file for two staff members. You may consider requiring potential employees to submit this letter with their application, so that a hard copy will be on file if they hired. All violations must be corrected immediately. You must submit documentation on how each violation was corrected to Ms. Childress by July 16, 2025. The documentation should be submitted by email to Ms. Childress at tammy.childress@dhhs.nc.gov. Include in the documentation the following: 1. Name of your facility and ID# 2. Date of the Visit 3. Date of the Documentation you are submitting 4. Each Item Number of the Violations Cited 5. Date of when each item number was corrected 6. How the item was corrected 7. Signature of the person submitting the documentation Your compliance history affects the star rating. It is imperative that staff maintain compliance with child care rules and requirements at all times. Violations of child care requirements affect the facility’s compliance history. You must maintain a minimum compliance history of seventy-five (75) percent. During the Pre-Licensing Visits conducted on May 21, 2025, and May 27, 2025, I discussed the process for rated license assessments as well as possible upcoming rule changes related to the Quality Rating and Improvement System (QRIS) Modernization, which were currently not in rule at the time of that visit with the owner of the facility. Resources including Smart Start of Forsyth County and the North Carolina Rated License Assessment Project website were also provided. An application for a Rated License Assessment, a Request for an Environment Rating Scale Assessment and a Quality Point option form were provided to you during today’s visit. On June 27, 2025, Ms. Williams-Mumford, owner, sent an email reply to me stating that she would like to be assessed for the final star rated license under the new child care rules and procedures with QRIS Modernization. Please submit by email the Rated License application and the Request for the Environment Rating Scale Assessment (if applicable) to me no later than August 1, 2025. Please ensure that all staff members have a WORKS Account and are updated with their correct educational information. The information on each staff member’s WORKS Qualification Letter and what is shown in the DCDEE WORKS system is what will be used to determine the points in education for your license. Instructions for the DCDEE WORKS system is located in the DCDEE website at https://ncchildcare.ncdhhs.gov. Register with Department of Justice You must register with the Department of Justice to receive e-mail or phone call notification if a sex offender moves into your area. To register, call 1-877-627-2826 or you may register on line at: http://sexoffender.ncdoj.gov/. To reference the law concerning Sex offender and Public Protection Registration Programs you may go to: http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_14/Article_27A.html. Contact the local Sheriff's Department if a sex offender email or phone notification is received from the NC Sex Offender Registry. Emergency Preparedness and Response Plan Emergency Preparedness and Response Training has been completed and you must complete an EPR Plan on a template at the following website https://rmp.nc.gov/portal/portal.aspx within four (4) months. A copy of the EPR plan must be printed and on file at the facility for review. After you complete the Emergency Preparedness and Response in Child Care training, you must conduct either a shelter-in-place or a lockdown drill every three months. Use the Emergency Drill Log to document these additional drills as well as the fire drills. The form is located under the Provider Documents tab on the DCDEE website at www.ncchildcare.ncdhhs.gov. The EPR Plan will be reviewed with all staff upon hire during orientation, whenever changes to the plan occur, and at least yearly. The date of the review of the plan with staff should be documented on the Staff and Training Worksheets. In addition, the administrator must review the plan annually in the portal and make updates if required. Once reviewed, print off the first page of the plan which will reflect the date of the review. A visit summary was prepared and a copy provided to Ms. Washington during the visit. If you have any further questions about today’s visit, please contact me at tammy.childress@dhhs.nc.gov or by telephone at (336)317-6436. You may also contact the Licensing Supervisor, Pamela Hauser, at pamela.hauser@dhhs.nc.gov if you have concerns regarding today’s visit or any violations documented. 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