G.S. 110-90 · Violation

Name of Operation: MADISON HIGH SCHOOL EARLY CHILDHOOD EDUCATION CENT Facility ID: 5755002 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/4/2025 Number Present: 11 Completed Date: 9/4/2025 Age: From 3 To 5 Total Minutes: 165 Time In: 09:30 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaitlyn Marshall, Child Care Consultant and also signed by Nicole Jobe, Lead Teacher, during the visit. A signed copy of the visit summary was emailed to you. Ms. Jobe was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, CPR/First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, adequate/approved space, program records, license posted. The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred percent (100%) as of 9/2/25. Permit type – Five (5) star license issued 1/23/25. Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. The facility is licensed to serve eighteen (18) children ages 2-6. The last annual compliance visit was conducted on 1/23/25. The last fire drill was practiced on 8/29/25. The last lockdown drill was practiced on 8/22/25. The last fire inspection was approved on 12/19/24. The last sanitation inspection was conducted on 4/10/25 with three (3) demerits for a superior classification. The Emergency Medical Care plan was posted and current. Lead water testing was completed on 8/15/24 without hazards. Lead paint and asbestos testing has not been completed. The status listed on the Clean Classroom for Carolina Kids website states "survey review by RTI". Continue to work with RTI and the public elementary school to complete testing as required. Upon arrival I was greeted by Ms. Jobe and Misty Hall, Early Childhood Education CTE Teacher. Children were engaged in free choice center play. Children explored various manipulatives, read books with puppets and pretended to be doctors in dramatic play. Interactions were positive and nurturing. Supervision was adequate. Donna Yost, Teacher, arrived at approximately 9:50am. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 1041 Prior to employment a Criminal Background Check was not completed. One (1) staff did not have a Criminal Background Check qualifying letter on file. G.S. 110-90.2(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff did not have a file available for review G.S. 110-91( 9) 1757 A valid qualification letter was not on file and available to review at the facility. One (1) staff did not have a Criminal Background Check qualifying letter on file G.S. 110-90.2(b) & (d) & .2703(e) 1867 The depth of the loose surfacing was not based on critical height of the equipment. The rubber mulch around the swings measured between three (3) and five (5) inches deep. The rubber mulch around the climber measured five (5) inches deep. .0605(k)(1-4) Technical assistance was provided as follows: Item #1041 and 1757: All staff who serve in ratio or are left alone with children must have a Criminal Background Check (CBC) qualifying letter on file. Staff M. Hall was serving in ratio during the visit today but does not have a copy of the CBC qualifying letter on file nor was I able to locate the staff’s qualification status in the ABCMS system. In your letter of compliance, you must provide a plan for how this staff member will participate in the licensed child care program. We discussed the following options: -The staff does not enter the licensed child care program. -The staff enters the program as a volunteer once all requirements for a volunteer file are met. The Volunteer File Checklist is attached to the email containing this visit summary. -The staff receives a CBC qualifying letter and all paperwork required for a Substitute provider and is able to serve in ratio and be left alone with children in the licensed child care program. The Substitute file checklist is attached to the email containing this visit summary. The unqualified staff member cannot enter the licensed child care classroom until one of the plans listed above has been implemented. We discussed that back-to-back violations regarding Criminal Background Checks may result in an Administrative Action recommendation. Item #1043: All staff and volunteers who provide care to children who enter the licensed child care space must have a staff or volunteer file available for review. In your letter of compliance, please include a statement that indicates how you will identify this staff member moving forward and include any plans to maintain the required paperwork on file. Item #1867: The rubber mulch much meet the adequate depth based on the critical height of the structures and swings. According to rule .0605(k) the depth of loose surfacing must be six (6) inches deep if the critical height of the equipment is up to seven (7) feet. Nine (9) inches of surfacing is required if the equipment has a critical height of seven (7) to ten (10) feet. The critical height is the tallest point that a child may sit or stand on the equipment. You can try to rake the mulch to ensure none is packed down from use and weather and redistribute mulch into the fall zones to achieve the adequate depth. If you add more rubber mulch to reach the required depth, ensure that the material has been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292. Retain any documentation that accompanies the mulch in your records. You cannot mix materials for surfacing. For example, you cannot add wood mulch to the rubber mulch. If you would like to change the surfacing, all existing surfacing must be removed. To reach compliance for this item, the adequate depth of surfacing must be reached. If it will take longer than two (2) weeks to receive the materials needed, you can physically block off the climbing structures so that children cannot use them, as a temporary compliance measure. In your letter of compliance, please indicate how you will block off the structures until adequate depth is met. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/18/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall PO Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: While Ms. Hall is waiting for the qualifying letter, you will need to make another plan in the case of staff absences. You cannot operate out of ratio as this is a safety concern. We discussed the following options in the case of a staff absence: -call a qualified substitute to cover the missing staff -close the classroom for the day -limit the attendance for the day so the ratio is met for one (1) staff Ms. Gahagan has a CBC qualifying letter on file and can be present in the facility and can serve in ratio for brief, emergency periods. However, Ms. Gahagan will need to meet the additional requirements such as CPR/First Aid, TB test/screening, Medical report, Shaken Baby Syndrome and Abusive Head Trauma policy, etc. if she will cover staff regularly. We discussed you are interested in changing the age range on the license from 2-6 years old to 3-5 years old or 3-6 years old. I am not able to locate a letter from Lisa Gahagan, Administrator, requesting the change. Ms. Gahagan will need to send me a letter requesting the age range in order for me to process the new license. The letter can be sent via email. We discussed the changes released in the Raise NC newsletter on 8/15/25 regarding proposed rule changes. Currently, these rules are still listed on the website as “proposed amendments”. The proposed effective date is 10/1/25, however we will provide technical assistance on these changes prior to citing violations. Plan to visit the Division’s website to learn more about proposed rule changes: https://ncchildcare.ncdhhs.gov/Services/Child-Care-Rules-Law-and-Public-Information Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

G.S. 110-91 · Violation

Name of Operation: MADISON HIGH SCHOOL EARLY CHILDHOOD EDUCATION CENT Facility ID: 5755002 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/4/2025 Number Present: 11 Completed Date: 9/4/2025 Age: From 3 To 5 Total Minutes: 165 Time In: 09:30 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaitlyn Marshall, Child Care Consultant and also signed by Nicole Jobe, Lead Teacher, during the visit. A signed copy of the visit summary was emailed to you. Ms. Jobe was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, CPR/First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, adequate/approved space, program records, license posted. The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred percent (100%) as of 9/2/25. Permit type – Five (5) star license issued 1/23/25. Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. The facility is licensed to serve eighteen (18) children ages 2-6. The last annual compliance visit was conducted on 1/23/25. The last fire drill was practiced on 8/29/25. The last lockdown drill was practiced on 8/22/25. The last fire inspection was approved on 12/19/24. The last sanitation inspection was conducted on 4/10/25 with three (3) demerits for a superior classification. The Emergency Medical Care plan was posted and current. Lead water testing was completed on 8/15/24 without hazards. Lead paint and asbestos testing has not been completed. The status listed on the Clean Classroom for Carolina Kids website states "survey review by RTI". Continue to work with RTI and the public elementary school to complete testing as required. Upon arrival I was greeted by Ms. Jobe and Misty Hall, Early Childhood Education CTE Teacher. Children were engaged in free choice center play. Children explored various manipulatives, read books with puppets and pretended to be doctors in dramatic play. Interactions were positive and nurturing. Supervision was adequate. Donna Yost, Teacher, arrived at approximately 9:50am. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 1041 Prior to employment a Criminal Background Check was not completed. One (1) staff did not have a Criminal Background Check qualifying letter on file. G.S. 110-90.2(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff did not have a file available for review G.S. 110-91( 9) 1757 A valid qualification letter was not on file and available to review at the facility. One (1) staff did not have a Criminal Background Check qualifying letter on file G.S. 110-90.2(b) & (d) & .2703(e) 1867 The depth of the loose surfacing was not based on critical height of the equipment. The rubber mulch around the swings measured between three (3) and five (5) inches deep. The rubber mulch around the climber measured five (5) inches deep. .0605(k)(1-4) Technical assistance was provided as follows: Item #1041 and 1757: All staff who serve in ratio or are left alone with children must have a Criminal Background Check (CBC) qualifying letter on file. Staff M. Hall was serving in ratio during the visit today but does not have a copy of the CBC qualifying letter on file nor was I able to locate the staff’s qualification status in the ABCMS system. In your letter of compliance, you must provide a plan for how this staff member will participate in the licensed child care program. We discussed the following options: -The staff does not enter the licensed child care program. -The staff enters the program as a volunteer once all requirements for a volunteer file are met. The Volunteer File Checklist is attached to the email containing this visit summary. -The staff receives a CBC qualifying letter and all paperwork required for a Substitute provider and is able to serve in ratio and be left alone with children in the licensed child care program. The Substitute file checklist is attached to the email containing this visit summary. The unqualified staff member cannot enter the licensed child care classroom until one of the plans listed above has been implemented. We discussed that back-to-back violations regarding Criminal Background Checks may result in an Administrative Action recommendation. Item #1043: All staff and volunteers who provide care to children who enter the licensed child care space must have a staff or volunteer file available for review. In your letter of compliance, please include a statement that indicates how you will identify this staff member moving forward and include any plans to maintain the required paperwork on file. Item #1867: The rubber mulch much meet the adequate depth based on the critical height of the structures and swings. According to rule .0605(k) the depth of loose surfacing must be six (6) inches deep if the critical height of the equipment is up to seven (7) feet. Nine (9) inches of surfacing is required if the equipment has a critical height of seven (7) to ten (10) feet. The critical height is the tallest point that a child may sit or stand on the equipment. You can try to rake the mulch to ensure none is packed down from use and weather and redistribute mulch into the fall zones to achieve the adequate depth. If you add more rubber mulch to reach the required depth, ensure that the material has been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292. Retain any documentation that accompanies the mulch in your records. You cannot mix materials for surfacing. For example, you cannot add wood mulch to the rubber mulch. If you would like to change the surfacing, all existing surfacing must be removed. To reach compliance for this item, the adequate depth of surfacing must be reached. If it will take longer than two (2) weeks to receive the materials needed, you can physically block off the climbing structures so that children cannot use them, as a temporary compliance measure. In your letter of compliance, please indicate how you will block off the structures until adequate depth is met. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/18/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall PO Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: While Ms. Hall is waiting for the qualifying letter, you will need to make another plan in the case of staff absences. You cannot operate out of ratio as this is a safety concern. We discussed the following options in the case of a staff absence: -call a qualified substitute to cover the missing staff -close the classroom for the day -limit the attendance for the day so the ratio is met for one (1) staff Ms. Gahagan has a CBC qualifying letter on file and can be present in the facility and can serve in ratio for brief, emergency periods. However, Ms. Gahagan will need to meet the additional requirements such as CPR/First Aid, TB test/screening, Medical report, Shaken Baby Syndrome and Abusive Head Trauma policy, etc. if she will cover staff regularly. We discussed you are interested in changing the age range on the license from 2-6 years old to 3-5 years old or 3-6 years old. I am not able to locate a letter from Lisa Gahagan, Administrator, requesting the change. Ms. Gahagan will need to send me a letter requesting the age range in order for me to process the new license. The letter can be sent via email. We discussed the changes released in the Raise NC newsletter on 8/15/25 regarding proposed rule changes. Currently, these rules are still listed on the website as “proposed amendments”. The proposed effective date is 10/1/25, however we will provide technical assistance on these changes prior to citing violations. Plan to visit the Division’s website to learn more about proposed rule changes: https://ncchildcare.ncdhhs.gov/Services/Child-Care-Rules-Law-and-Public-Information Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

NC GS 110-90 · Violation

Name of Operation: MADISON HIGH SCHOOL EARLY CHILDHOOD EDUCATION CENT Facility ID: 5755002 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/4/2025 Number Present: 11 Completed Date: 9/4/2025 Age: From 3 To 5 Total Minutes: 165 Time In: 09:30 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaitlyn Marshall, Child Care Consultant and also signed by Nicole Jobe, Lead Teacher, during the visit. A signed copy of the visit summary was emailed to you. Ms. Jobe was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, CPR/First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, adequate/approved space, program records, license posted. The center’s compliance history was reviewed with the operator. The program’s compliance history was one hundred percent (100%) as of 9/2/25. Permit type – Five (5) star license issued 1/23/25. Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. The facility is licensed to serve eighteen (18) children ages 2-6. The last annual compliance visit was conducted on 1/23/25. The last fire drill was practiced on 8/29/25. The last lockdown drill was practiced on 8/22/25. The last fire inspection was approved on 12/19/24. The last sanitation inspection was conducted on 4/10/25 with three (3) demerits for a superior classification. The Emergency Medical Care plan was posted and current. Lead water testing was completed on 8/15/24 without hazards. Lead paint and asbestos testing has not been completed. The status listed on the Clean Classroom for Carolina Kids website states "survey review by RTI". Continue to work with RTI and the public elementary school to complete testing as required. Upon arrival I was greeted by Ms. Jobe and Misty Hall, Early Childhood Education CTE Teacher. Children were engaged in free choice center play. Children explored various manipulatives, read books with puppets and pretended to be doctors in dramatic play. Interactions were positive and nurturing. Supervision was adequate. Donna Yost, Teacher, arrived at approximately 9:50am. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 1041 Prior to employment a Criminal Background Check was not completed. One (1) staff did not have a Criminal Background Check qualifying letter on file. G.S. 110-90.2(b) 1043 All staff records, except financial records, were not made available for review. One (1) staff did not have a file available for review G.S. 110-91( 9) 1757 A valid qualification letter was not on file and available to review at the facility. One (1) staff did not have a Criminal Background Check qualifying letter on file G.S. 110-90.2(b) & (d) & .2703(e) 1867 The depth of the loose surfacing was not based on critical height of the equipment. The rubber mulch around the swings measured between three (3) and five (5) inches deep. The rubber mulch around the climber measured five (5) inches deep. .0605(k)(1-4) Technical assistance was provided as follows: Item #1041 and 1757: All staff who serve in ratio or are left alone with children must have a Criminal Background Check (CBC) qualifying letter on file. Staff M. Hall was serving in ratio during the visit today but does not have a copy of the CBC qualifying letter on file nor was I able to locate the staff’s qualification status in the ABCMS system. In your letter of compliance, you must provide a plan for how this staff member will participate in the licensed child care program. We discussed the following options: -The staff does not enter the licensed child care program. -The staff enters the program as a volunteer once all requirements for a volunteer file are met. The Volunteer File Checklist is attached to the email containing this visit summary. -The staff receives a CBC qualifying letter and all paperwork required for a Substitute provider and is able to serve in ratio and be left alone with children in the licensed child care program. The Substitute file checklist is attached to the email containing this visit summary. The unqualified staff member cannot enter the licensed child care classroom until one of the plans listed above has been implemented. We discussed that back-to-back violations regarding Criminal Background Checks may result in an Administrative Action recommendation. Item #1043: All staff and volunteers who provide care to children who enter the licensed child care space must have a staff or volunteer file available for review. In your letter of compliance, please include a statement that indicates how you will identify this staff member moving forward and include any plans to maintain the required paperwork on file. Item #1867: The rubber mulch much meet the adequate depth based on the critical height of the structures and swings. According to rule .0605(k) the depth of loose surfacing must be six (6) inches deep if the critical height of the equipment is up to seven (7) feet. Nine (9) inches of surfacing is required if the equipment has a critical height of seven (7) to ten (10) feet. The critical height is the tallest point that a child may sit or stand on the equipment. You can try to rake the mulch to ensure none is packed down from use and weather and redistribute mulch into the fall zones to achieve the adequate depth. If you add more rubber mulch to reach the required depth, ensure that the material has been certified by the manufacturer to be shock-absorbing protective material in accordance with the American Society for Testing and Materials (ASTM) Standard F 1292. Retain any documentation that accompanies the mulch in your records. You cannot mix materials for surfacing. For example, you cannot add wood mulch to the rubber mulch. If you would like to change the surfacing, all existing surfacing must be removed. To reach compliance for this item, the adequate depth of surfacing must be reached. If it will take longer than two (2) weeks to receive the materials needed, you can physically block off the climbing structures so that children cannot use them, as a temporary compliance measure. In your letter of compliance, please indicate how you will block off the structures until adequate depth is met. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/18/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall PO Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: While Ms. Hall is waiting for the qualifying letter, you will need to make another plan in the case of staff absences. You cannot operate out of ratio as this is a safety concern. We discussed the following options in the case of a staff absence: -call a qualified substitute to cover the missing staff -close the classroom for the day -limit the attendance for the day so the ratio is met for one (1) staff Ms. Gahagan has a CBC qualifying letter on file and can be present in the facility and can serve in ratio for brief, emergency periods. However, Ms. Gahagan will need to meet the additional requirements such as CPR/First Aid, TB test/screening, Medical report, Shaken Baby Syndrome and Abusive Head Trauma policy, etc. if she will cover staff regularly. We discussed you are interested in changing the age range on the license from 2-6 years old to 3-5 years old or 3-6 years old. I am not able to locate a letter from Lisa Gahagan, Administrator, requesting the change. Ms. Gahagan will need to send me a letter requesting the age range in order for me to process the new license. The letter can be sent via email. We discussed the changes released in the Raise NC newsletter on 8/15/25 regarding proposed rule changes. Currently, these rules are still listed on the website as “proposed amendments”. The proposed effective date is 10/1/25, however we will provide technical assistance on these changes prior to citing violations. Plan to visit the Division’s website to learn more about proposed rule changes: https://ncchildcare.ncdhhs.gov/Services/Child-Care-Rules-Law-and-Public-Information Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times