Christ OUR Shepherd Child Care

10A NCAC 09 .0803 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 6/4/2026 Number Present: 70 Completed Date: 6/4/2026 Age: From 0 To 5 Total Minutes: 160 Time In: 09:45 AM Time Out: 12:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for a routine unannounced visit. The facility has a Five-Star License issued November 19, 2019, with enhanced space and ratio. An eighteen-month compliance history score of 80 % prior to today’s visit. The last Annual Compliance Visit was conducted November 24, 2025. Upon arrival, I was greeted by Robin Havican, Business Manager, Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. I conducted a walkthrough of the facility with Ms. Williams and monitored all indoor areas of the facility. I observed children engaged in tummy time, personal care routines, sleep, free play, outdoor play, activity centers, transitions and teacher directed activities. There have been three (3) new staff hired since the annual compliance visit. I reviewed the new employee files and found one CPR/First Aid violation. See violations section for details. The following items were monitored today: License Posted/Permit Restrictions: The license was posted, and restrictions were in compliance. Supervision: Each group of children was adequately supervised during the visit. Staff/Child Ratio: The ratios were maintained during today’s visit. CPR: One staff member has CPR certificate on file from an agency not approved by DCDEE. A violation was cited. First Aid: One staff member has First Aid certificate on file from an agency not approved by DCDEE. A violation was cited. CBC Qualification: Staff were current with Criminal Background Check (CBC) qualification. ABCMS roster requirements were in compliance ITS-SIDS: Staff requiring ITS-SIDS certification were current and in compliance. Safe sleep policy and sleep charts: I observed the safe sleep policy and monitored safe sleep checks and found in compliance. Emergency Medical Care Plan: The Emergency Care Plan was posted and current. Administration of Medication: Diaper creams were monitored and found in compliance. There is currently one Emergency Medication in the facility and it was not in compliance. See violation section for details. Storage of Hazardous Substances: All hazardous materials were stored properly. Storage of Medication: All medication was observed stored in compliance. General Safety: General safety was found in compliance. Discipline: There were no discipline concerns; appropriate discipline was provided. Nurturing tones were heard when staff spoke with children. Adequate/Approved Space: Each group of children were observed in licensed approved space. Program Records: Program records were reviewed and found in compliance. The playground inspections and the incident log were in compliance. The EPR is dated November 24, 2025, and the ready-to-go file was monitored and found in compliance. The last sanitation inspection was June 2, 2026, with a superior rating. The last fire inspection was July 31, 2025. The following violations were cited today: Violation Number Comment Rule 847 Parent's medication authorization did not include required information. The permission to administer form for one child requiring an epi-pen expired 4/7/2026. 10A NCAC 09 .0803(4)(6-9) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One staff member hired 2/9/2026 did not have a First Aid certification on file from and approved agency. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One staff member hired 2/9/2026 did not have a CPR certification on file from and approved agency. .1102(d) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. One child requiring emergency medication had an expired FARE plan on file dated 5/19/2025. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Compliance Statement: 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 June 18, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Emergency Medications We discussed reviewing the emergency medication requirements found in 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS with your staff and establishing a spreadsheet for routine reviews. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/ on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. Additionally, we have resources available specific to NC Pre-K at https://ncchildcare.ncdhhs.gov/Home/DCDEE-Sections/North-Carolina-Pre-Kindergarten-NC-Pre-K QRIS/Pathway to the Stars We discussed that you are planning to complete Pathway 3 upon completing NAEYC Accreditation. You have determined that you will reduce your license to One Star effective November 1, 2026, and apply for a rated license using Pathway 3 upon completion of the accreditation. Please submit a detailed email outlining your decision to reduce your license to One Star to me. I will process your new permit effective November 1, 2026. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270 or Amy Italiano, Licensing Supervisor at amy.italiano@dhhs.nc.gov or 704-936-6065. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 6/4/2026 Number Present: 70 Completed Date: 6/4/2026 Age: From 0 To 5 Total Minutes: 160 Time In: 09:45 AM Time Out: 12:25 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for a routine unannounced visit. The facility has a Five-Star License issued November 19, 2019, with enhanced space and ratio. An eighteen-month compliance history score of 80 % prior to today’s visit. The last Annual Compliance Visit was conducted November 24, 2025. Upon arrival, I was greeted by Robin Havican, Business Manager, Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. I conducted a walkthrough of the facility with Ms. Williams and monitored all indoor areas of the facility. I observed children engaged in tummy time, personal care routines, sleep, free play, outdoor play, activity centers, transitions and teacher directed activities. There have been three (3) new staff hired since the annual compliance visit. I reviewed the new employee files and found one CPR/First Aid violation. See violations section for details. The following items were monitored today: License Posted/Permit Restrictions: The license was posted, and restrictions were in compliance. Supervision: Each group of children was adequately supervised during the visit. Staff/Child Ratio: The ratios were maintained during today’s visit. CPR: One staff member has CPR certificate on file from an agency not approved by DCDEE. A violation was cited. First Aid: One staff member has First Aid certificate on file from an agency not approved by DCDEE. A violation was cited. CBC Qualification: Staff were current with Criminal Background Check (CBC) qualification. ABCMS roster requirements were in compliance ITS-SIDS: Staff requiring ITS-SIDS certification were current and in compliance. Safe sleep policy and sleep charts: I observed the safe sleep policy and monitored safe sleep checks and found in compliance. Emergency Medical Care Plan: The Emergency Care Plan was posted and current. Administration of Medication: Diaper creams were monitored and found in compliance. There is currently one Emergency Medication in the facility and it was not in compliance. See violation section for details. Storage of Hazardous Substances: All hazardous materials were stored properly. Storage of Medication: All medication was observed stored in compliance. General Safety: General safety was found in compliance. Discipline: There were no discipline concerns; appropriate discipline was provided. Nurturing tones were heard when staff spoke with children. Adequate/Approved Space: Each group of children were observed in licensed approved space. Program Records: Program records were reviewed and found in compliance. The playground inspections and the incident log were in compliance. The EPR is dated November 24, 2025, and the ready-to-go file was monitored and found in compliance. The last sanitation inspection was June 2, 2026, with a superior rating. The last fire inspection was July 31, 2025. The following violations were cited today: Violation Number Comment Rule 847 Parent's medication authorization did not include required information. The permission to administer form for one child requiring an epi-pen expired 4/7/2026. 10A NCAC 09 .0803(4)(6-9) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One staff member hired 2/9/2026 did not have a First Aid certification on file from and approved agency. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One staff member hired 2/9/2026 did not have a CPR certification on file from and approved agency. .1102(d) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. One child requiring emergency medication had an expired FARE plan on file dated 5/19/2025. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Compliance Statement: 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 June 18, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Emergency Medications We discussed reviewing the emergency medication requirements found in 10A NCAC 09 .0803 ADMINISTERING MEDICATION IN CHILD CARE CENTERS with your staff and establishing a spreadsheet for routine reviews. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/ on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. Additionally, we have resources available specific to NC Pre-K at https://ncchildcare.ncdhhs.gov/Home/DCDEE-Sections/North-Carolina-Pre-Kindergarten-NC-Pre-K QRIS/Pathway to the Stars We discussed that you are planning to complete Pathway 3 upon completing NAEYC Accreditation. You have determined that you will reduce your license to One Star effective November 1, 2026, and apply for a rated license using Pathway 3 upon completion of the accreditation. Please submit a detailed email outlining your decision to reduce your license to One Star to me. I will process your new permit effective November 1, 2026. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270 or Amy Italiano, Licensing Supervisor at amy.italiano@dhhs.nc.gov or 704-936-6065. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0601 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 11/24/2025 Number Present: 54 Completed Date: 11/24/2025 Age: From 0 To 4 Total Minutes: 283 Time In: 09:07 AM Time Out: 01:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for an annual compliance visit. The facility currently operates with a five-star license, issued November 19, 2019. The last annual compliance visit was conducted on January 7, 2025. Upon arrival, I was greeted by Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. The NC Secretary of State website was reviewed on November 21, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 82%. A sanitation inspection was completed November 4, 2025, with a Superior classification. The last fire inspection was conducted July 31, 2025. The fire inspection was not received by the Division until October 21, 2025. A violation was cited. A walk-through of the facility was completed today including all indoor and outdoor areas. The center does not provide transportation. During the walk through, I observed children in both the indoor and outdoor learning environments and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in personal care routines, indoor activity areas, circle time, outdoor play , music and teacher directed activities. Activity plans were posted, and materials were available, in good repair and age appropriate. Staff/child ratio was in compliance, nurturing and caring tones were heard throughout the facility. Rooms serving infants and toddlers were monitored for safe sleep checks, required posted items, feeding schedules, labeled and dated bottles or cups and diaper creams. Small parts, storage of hazardous materials and general safety were monitored. Violations were cited. Please review the violations section for details. Topical ointments were monitored throughout the center and found in compliance There is currently one (1) child enrolled requiring Emergency Medication. All documents, storage and expiration dates were found in compliance. The outdoor play areas were monitored. General safety violations on the play area serving preschoolers were cited. Program records were reviewed and found in compliance. The last fire drill was conducted on October 30, 2025. The last shelter in place was conducted on October 22, 2025. The playground inspections both outdoor play areas and the incident log were in compliance. The EPR plan is currently being updated. The current plan will expire November 26,2024. The ready-to-go file was observed available and in compliance. Staff and Training Worksheets were provided. Six (6) new staff members have been employed since the last annual compliance visit. I reviewed all new employee files and then (10) percent of veteran files. Please see violations section for details regarding items cited. ABCMS was monitored and found in compliance. Ten (10) percent of children’s records were monitored and found in compliance. The following violations were cited today: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection dated 7/31/2025 was received by the Division 10/21/2025. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. On the play area serving preschoolers there was rotted wood on a planter boarder, rusty tricycles, and a storage bin full of water. 10A NCAC 09 .0601(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. In Space 2, a Magic Eraser was stored accessible to children in an unlocked cabinet lower than five (5) feet. In Space 8, hand sanitizer was observed by a sink accessible to children. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 1 bags and baggies were stored in cubbies accessible to children. In Space 4 , plastic bags storing clothing was in a cubby accessible to children. .0604(q) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member hired 5/16/2019 had a medical report on file dated 7/9/2019. One (1) staff member hired 2/17/2025 had a medical assessment on file dated 3/4/2025. 10A NCAC 09 .0701(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved First Aid Certification from National CPR Foundation on file. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved CPR Certification from National CPR Foundation on file. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. One (1) veteran staff member hired 8/29/05 needed 4 additional on going training hours by 8/29/2025. .1103(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Four (4) new staff members received 4.75 hours documented training during first two weeks of employment. .1101(a)(b) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One (1) veteran staff member hired 5/16/19 did not complete Administration of Medication training. .1103(b) Compliance Statement 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 December 8, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance QRIS/Pathway to the Stars We discussed the pathway, timeline, and resources needed for your rated license. The Division has a timeline for transitioning to current Pathway to the Stars by December 2026. You plan to move forward with Pathway 1. The facility is currently enrolled with Quality Everyday and are receiving technical assistance to prepare for your Rated Licenses Assessments. You requested additional information regarding approved formative assessments. Approved formative assessments can be found on our website here: https://ncchildcare.ncdhhs.gov/Services/Licensing/Star-Rated-License/Curriculum. We discussed that Pathway 1 does not require formative assessments. Staff Records We discussed documenting orientation hours, on-going hours, signatures and importance of dates on all staff files. There is significant improvement in documentation and organization of your staff files since the last annual compliance visit. Storage of Hazardous Materials and Small Parts We discussed developing a formal checklist monitoring tool for your administrative and classroom staff daily. Approved CPR/FA Training Please visit here to get information regarding approved trainers: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training NC Rated License Project We discussed that you can train and equip your teachers using the resources for Get Ready for the 3’s / QRIS. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. New Rules Effective July 1, 2025, Now Available Please bookmark Chapter 9 to reference the most current rules effective July 1, 2025. https://ncchildcare.ncdhhs.gov/Portals/0/documents/pdf/C/Chapter_9_Child_Care_Rules_Effective_July_1_2025.pdf?ver=9gQO5ZV3KdVI8BanULluoA%3d%3d Staff WORKS Letters We discussed keeping your staff WORKS Letters up to date and on file. You can access more information here: https://ncchildcare.ncdhhs.gov/Services/DCDEE-WORKS NC FELD Training We discussed utilizing the NC Foundations for Early Learning and Development resource book. I recommend taking the NC FELD training offered through Child Care Resources. The training description and calendar can be accessed here: https://www.childcareresourcesinc.org/training . CCRI will also contract training for your facility if you are interested. MOODLE Staff Orientation We discussed that Moodle now offers orientation and child development training for your staff. Moodle can be accessed here: https://www.dcdee.moodle.nc.gov/ HEALTHY SOCIAL BEHAVIORS PROJECT Supporting teachers to develop pro-social early childhood learning environments that help to prevent suspension and expulsion, as related to challenging behaviors. We are specialists with early childhood education backgrounds who are passionate about empowering teachers to develop learning environments that promote pro-social skills in young children. Our statewide team includes behavior specialists, fidelity coaches, an education specialist, and a project manager covering all 100 counties in North Carolina. The Healthy Social Behaviors project is an initiative of the North Carolina Resource and Referral Council funded by the North Carolina Department of Child Development and Early Education (DCDEE). Contact Stephanie Dreyer, Child Care Resources Inc. 704-376-6697 x 120 | sdreyer@childcareresourcesinc.org for more information. Child Care Resources Technical Assistance Let CCRI come to you! Child Care Resources Inc. provides technical assistance to help you enhance the quality of care you provide for children and families. Our specialists work at your site — with individual classrooms or your entire program — to help you meet short- or long-term goals, maintain higher quality, address your professional development needs, and support program start-up or corrective action requirements. For more information visit: https://www.childcareresourcesinc.org/technical-assistance Technical assistance is guided by a collaboratively developed action plan to accomplish your goals. Support may be episodic or year-long, broadly or narrowly focused. Directors Leadership Network Serving as the director of a child care center means responding to competing needs and demands on your time as you manage the many responsibilities of running a quality program – maintaining compliance with licensing requirements, nurturing children, supporting families, and developing your staff. No wonder you feel like there’s no time for you! Directors Leadership Network powered by CCRI is a way for CCRI to support you as you support one another. As one member stated, “Directors Leadership Network is my opportunity for professional self-care.” If you are looking for a warm and friendly forum to ask questions, share ideas, relieve stress, and receive and offer support among your professional peers, then Directors Leadership Network powered by CCRI is the place for you! For more information, visit https://www.childcareresourcesinc.org/more-resources-1. Reminder Continue to review emails from the Division of Child Development and Early Education (DCDEE) and from your assigned child care consultant. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0304 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 11/24/2025 Number Present: 54 Completed Date: 11/24/2025 Age: From 0 To 4 Total Minutes: 283 Time In: 09:07 AM Time Out: 01:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for an annual compliance visit. The facility currently operates with a five-star license, issued November 19, 2019. The last annual compliance visit was conducted on January 7, 2025. Upon arrival, I was greeted by Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. The NC Secretary of State website was reviewed on November 21, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 82%. A sanitation inspection was completed November 4, 2025, with a Superior classification. The last fire inspection was conducted July 31, 2025. The fire inspection was not received by the Division until October 21, 2025. A violation was cited. A walk-through of the facility was completed today including all indoor and outdoor areas. The center does not provide transportation. During the walk through, I observed children in both the indoor and outdoor learning environments and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in personal care routines, indoor activity areas, circle time, outdoor play , music and teacher directed activities. Activity plans were posted, and materials were available, in good repair and age appropriate. Staff/child ratio was in compliance, nurturing and caring tones were heard throughout the facility. Rooms serving infants and toddlers were monitored for safe sleep checks, required posted items, feeding schedules, labeled and dated bottles or cups and diaper creams. Small parts, storage of hazardous materials and general safety were monitored. Violations were cited. Please review the violations section for details. Topical ointments were monitored throughout the center and found in compliance There is currently one (1) child enrolled requiring Emergency Medication. All documents, storage and expiration dates were found in compliance. The outdoor play areas were monitored. General safety violations on the play area serving preschoolers were cited. Program records were reviewed and found in compliance. The last fire drill was conducted on October 30, 2025. The last shelter in place was conducted on October 22, 2025. The playground inspections both outdoor play areas and the incident log were in compliance. The EPR plan is currently being updated. The current plan will expire November 26,2024. The ready-to-go file was observed available and in compliance. Staff and Training Worksheets were provided. Six (6) new staff members have been employed since the last annual compliance visit. I reviewed all new employee files and then (10) percent of veteran files. Please see violations section for details regarding items cited. ABCMS was monitored and found in compliance. Ten (10) percent of children’s records were monitored and found in compliance. The following violations were cited today: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection dated 7/31/2025 was received by the Division 10/21/2025. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. On the play area serving preschoolers there was rotted wood on a planter boarder, rusty tricycles, and a storage bin full of water. 10A NCAC 09 .0601(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. In Space 2, a Magic Eraser was stored accessible to children in an unlocked cabinet lower than five (5) feet. In Space 8, hand sanitizer was observed by a sink accessible to children. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 1 bags and baggies were stored in cubbies accessible to children. In Space 4 , plastic bags storing clothing was in a cubby accessible to children. .0604(q) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member hired 5/16/2019 had a medical report on file dated 7/9/2019. One (1) staff member hired 2/17/2025 had a medical assessment on file dated 3/4/2025. 10A NCAC 09 .0701(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved First Aid Certification from National CPR Foundation on file. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved CPR Certification from National CPR Foundation on file. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. One (1) veteran staff member hired 8/29/05 needed 4 additional on going training hours by 8/29/2025. .1103(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Four (4) new staff members received 4.75 hours documented training during first two weeks of employment. .1101(a)(b) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One (1) veteran staff member hired 5/16/19 did not complete Administration of Medication training. .1103(b) Compliance Statement 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 December 8, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance QRIS/Pathway to the Stars We discussed the pathway, timeline, and resources needed for your rated license. The Division has a timeline for transitioning to current Pathway to the Stars by December 2026. You plan to move forward with Pathway 1. The facility is currently enrolled with Quality Everyday and are receiving technical assistance to prepare for your Rated Licenses Assessments. You requested additional information regarding approved formative assessments. Approved formative assessments can be found on our website here: https://ncchildcare.ncdhhs.gov/Services/Licensing/Star-Rated-License/Curriculum. We discussed that Pathway 1 does not require formative assessments. Staff Records We discussed documenting orientation hours, on-going hours, signatures and importance of dates on all staff files. There is significant improvement in documentation and organization of your staff files since the last annual compliance visit. Storage of Hazardous Materials and Small Parts We discussed developing a formal checklist monitoring tool for your administrative and classroom staff daily. Approved CPR/FA Training Please visit here to get information regarding approved trainers: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training NC Rated License Project We discussed that you can train and equip your teachers using the resources for Get Ready for the 3’s / QRIS. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. New Rules Effective July 1, 2025, Now Available Please bookmark Chapter 9 to reference the most current rules effective July 1, 2025. https://ncchildcare.ncdhhs.gov/Portals/0/documents/pdf/C/Chapter_9_Child_Care_Rules_Effective_July_1_2025.pdf?ver=9gQO5ZV3KdVI8BanULluoA%3d%3d Staff WORKS Letters We discussed keeping your staff WORKS Letters up to date and on file. You can access more information here: https://ncchildcare.ncdhhs.gov/Services/DCDEE-WORKS NC FELD Training We discussed utilizing the NC Foundations for Early Learning and Development resource book. I recommend taking the NC FELD training offered through Child Care Resources. The training description and calendar can be accessed here: https://www.childcareresourcesinc.org/training . CCRI will also contract training for your facility if you are interested. MOODLE Staff Orientation We discussed that Moodle now offers orientation and child development training for your staff. Moodle can be accessed here: https://www.dcdee.moodle.nc.gov/ HEALTHY SOCIAL BEHAVIORS PROJECT Supporting teachers to develop pro-social early childhood learning environments that help to prevent suspension and expulsion, as related to challenging behaviors. We are specialists with early childhood education backgrounds who are passionate about empowering teachers to develop learning environments that promote pro-social skills in young children. Our statewide team includes behavior specialists, fidelity coaches, an education specialist, and a project manager covering all 100 counties in North Carolina. The Healthy Social Behaviors project is an initiative of the North Carolina Resource and Referral Council funded by the North Carolina Department of Child Development and Early Education (DCDEE). Contact Stephanie Dreyer, Child Care Resources Inc. 704-376-6697 x 120 | sdreyer@childcareresourcesinc.org for more information. Child Care Resources Technical Assistance Let CCRI come to you! Child Care Resources Inc. provides technical assistance to help you enhance the quality of care you provide for children and families. Our specialists work at your site — with individual classrooms or your entire program — to help you meet short- or long-term goals, maintain higher quality, address your professional development needs, and support program start-up or corrective action requirements. For more information visit: https://www.childcareresourcesinc.org/technical-assistance Technical assistance is guided by a collaboratively developed action plan to accomplish your goals. Support may be episodic or year-long, broadly or narrowly focused. Directors Leadership Network Serving as the director of a child care center means responding to competing needs and demands on your time as you manage the many responsibilities of running a quality program – maintaining compliance with licensing requirements, nurturing children, supporting families, and developing your staff. No wonder you feel like there’s no time for you! Directors Leadership Network powered by CCRI is a way for CCRI to support you as you support one another. As one member stated, “Directors Leadership Network is my opportunity for professional self-care.” If you are looking for a warm and friendly forum to ask questions, share ideas, relieve stress, and receive and offer support among your professional peers, then Directors Leadership Network powered by CCRI is the place for you! For more information, visit https://www.childcareresourcesinc.org/more-resources-1. Reminder Continue to review emails from the Division of Child Development and Early Education (DCDEE) and from your assigned child care consultant. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0701 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 11/24/2025 Number Present: 54 Completed Date: 11/24/2025 Age: From 0 To 4 Total Minutes: 283 Time In: 09:07 AM Time Out: 01:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for an annual compliance visit. The facility currently operates with a five-star license, issued November 19, 2019. The last annual compliance visit was conducted on January 7, 2025. Upon arrival, I was greeted by Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. The NC Secretary of State website was reviewed on November 21, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 82%. A sanitation inspection was completed November 4, 2025, with a Superior classification. The last fire inspection was conducted July 31, 2025. The fire inspection was not received by the Division until October 21, 2025. A violation was cited. A walk-through of the facility was completed today including all indoor and outdoor areas. The center does not provide transportation. During the walk through, I observed children in both the indoor and outdoor learning environments and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in personal care routines, indoor activity areas, circle time, outdoor play , music and teacher directed activities. Activity plans were posted, and materials were available, in good repair and age appropriate. Staff/child ratio was in compliance, nurturing and caring tones were heard throughout the facility. Rooms serving infants and toddlers were monitored for safe sleep checks, required posted items, feeding schedules, labeled and dated bottles or cups and diaper creams. Small parts, storage of hazardous materials and general safety were monitored. Violations were cited. Please review the violations section for details. Topical ointments were monitored throughout the center and found in compliance There is currently one (1) child enrolled requiring Emergency Medication. All documents, storage and expiration dates were found in compliance. The outdoor play areas were monitored. General safety violations on the play area serving preschoolers were cited. Program records were reviewed and found in compliance. The last fire drill was conducted on October 30, 2025. The last shelter in place was conducted on October 22, 2025. The playground inspections both outdoor play areas and the incident log were in compliance. The EPR plan is currently being updated. The current plan will expire November 26,2024. The ready-to-go file was observed available and in compliance. Staff and Training Worksheets were provided. Six (6) new staff members have been employed since the last annual compliance visit. I reviewed all new employee files and then (10) percent of veteran files. Please see violations section for details regarding items cited. ABCMS was monitored and found in compliance. Ten (10) percent of children’s records were monitored and found in compliance. The following violations were cited today: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection dated 7/31/2025 was received by the Division 10/21/2025. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. On the play area serving preschoolers there was rotted wood on a planter boarder, rusty tricycles, and a storage bin full of water. 10A NCAC 09 .0601(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. In Space 2, a Magic Eraser was stored accessible to children in an unlocked cabinet lower than five (5) feet. In Space 8, hand sanitizer was observed by a sink accessible to children. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 1 bags and baggies were stored in cubbies accessible to children. In Space 4 , plastic bags storing clothing was in a cubby accessible to children. .0604(q) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member hired 5/16/2019 had a medical report on file dated 7/9/2019. One (1) staff member hired 2/17/2025 had a medical assessment on file dated 3/4/2025. 10A NCAC 09 .0701(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved First Aid Certification from National CPR Foundation on file. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved CPR Certification from National CPR Foundation on file. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. One (1) veteran staff member hired 8/29/05 needed 4 additional on going training hours by 8/29/2025. .1103(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Four (4) new staff members received 4.75 hours documented training during first two weeks of employment. .1101(a)(b) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One (1) veteran staff member hired 5/16/19 did not complete Administration of Medication training. .1103(b) Compliance Statement 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 December 8, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance QRIS/Pathway to the Stars We discussed the pathway, timeline, and resources needed for your rated license. The Division has a timeline for transitioning to current Pathway to the Stars by December 2026. You plan to move forward with Pathway 1. The facility is currently enrolled with Quality Everyday and are receiving technical assistance to prepare for your Rated Licenses Assessments. You requested additional information regarding approved formative assessments. Approved formative assessments can be found on our website here: https://ncchildcare.ncdhhs.gov/Services/Licensing/Star-Rated-License/Curriculum. We discussed that Pathway 1 does not require formative assessments. Staff Records We discussed documenting orientation hours, on-going hours, signatures and importance of dates on all staff files. There is significant improvement in documentation and organization of your staff files since the last annual compliance visit. Storage of Hazardous Materials and Small Parts We discussed developing a formal checklist monitoring tool for your administrative and classroom staff daily. Approved CPR/FA Training Please visit here to get information regarding approved trainers: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training NC Rated License Project We discussed that you can train and equip your teachers using the resources for Get Ready for the 3’s / QRIS. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. New Rules Effective July 1, 2025, Now Available Please bookmark Chapter 9 to reference the most current rules effective July 1, 2025. https://ncchildcare.ncdhhs.gov/Portals/0/documents/pdf/C/Chapter_9_Child_Care_Rules_Effective_July_1_2025.pdf?ver=9gQO5ZV3KdVI8BanULluoA%3d%3d Staff WORKS Letters We discussed keeping your staff WORKS Letters up to date and on file. You can access more information here: https://ncchildcare.ncdhhs.gov/Services/DCDEE-WORKS NC FELD Training We discussed utilizing the NC Foundations for Early Learning and Development resource book. I recommend taking the NC FELD training offered through Child Care Resources. The training description and calendar can be accessed here: https://www.childcareresourcesinc.org/training . CCRI will also contract training for your facility if you are interested. MOODLE Staff Orientation We discussed that Moodle now offers orientation and child development training for your staff. Moodle can be accessed here: https://www.dcdee.moodle.nc.gov/ HEALTHY SOCIAL BEHAVIORS PROJECT Supporting teachers to develop pro-social early childhood learning environments that help to prevent suspension and expulsion, as related to challenging behaviors. We are specialists with early childhood education backgrounds who are passionate about empowering teachers to develop learning environments that promote pro-social skills in young children. Our statewide team includes behavior specialists, fidelity coaches, an education specialist, and a project manager covering all 100 counties in North Carolina. The Healthy Social Behaviors project is an initiative of the North Carolina Resource and Referral Council funded by the North Carolina Department of Child Development and Early Education (DCDEE). Contact Stephanie Dreyer, Child Care Resources Inc. 704-376-6697 x 120 | sdreyer@childcareresourcesinc.org for more information. Child Care Resources Technical Assistance Let CCRI come to you! Child Care Resources Inc. provides technical assistance to help you enhance the quality of care you provide for children and families. Our specialists work at your site — with individual classrooms or your entire program — to help you meet short- or long-term goals, maintain higher quality, address your professional development needs, and support program start-up or corrective action requirements. For more information visit: https://www.childcareresourcesinc.org/technical-assistance Technical assistance is guided by a collaboratively developed action plan to accomplish your goals. Support may be episodic or year-long, broadly or narrowly focused. Directors Leadership Network Serving as the director of a child care center means responding to competing needs and demands on your time as you manage the many responsibilities of running a quality program – maintaining compliance with licensing requirements, nurturing children, supporting families, and developing your staff. No wonder you feel like there’s no time for you! Directors Leadership Network powered by CCRI is a way for CCRI to support you as you support one another. As one member stated, “Directors Leadership Network is my opportunity for professional self-care.” If you are looking for a warm and friendly forum to ask questions, share ideas, relieve stress, and receive and offer support among your professional peers, then Directors Leadership Network powered by CCRI is the place for you! For more information, visit https://www.childcareresourcesinc.org/more-resources-1. Reminder Continue to review emails from the Division of Child Development and Early Education (DCDEE) and from your assigned child care consultant. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 11/24/2025 Number Present: 54 Completed Date: 11/24/2025 Age: From 0 To 4 Total Minutes: 283 Time In: 09:07 AM Time Out: 01:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for an annual compliance visit. The facility currently operates with a five-star license, issued November 19, 2019. The last annual compliance visit was conducted on January 7, 2025. Upon arrival, I was greeted by Heather Williamson, Director, and Addison Rush, Assistant Director. Ms. Williamson assisted me with the visit. The NC Secretary of State website was reviewed on November 21, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 82%. A sanitation inspection was completed November 4, 2025, with a Superior classification. The last fire inspection was conducted July 31, 2025. The fire inspection was not received by the Division until October 21, 2025. A violation was cited. A walk-through of the facility was completed today including all indoor and outdoor areas. The center does not provide transportation. During the walk through, I observed children in both the indoor and outdoor learning environments and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in personal care routines, indoor activity areas, circle time, outdoor play , music and teacher directed activities. Activity plans were posted, and materials were available, in good repair and age appropriate. Staff/child ratio was in compliance, nurturing and caring tones were heard throughout the facility. Rooms serving infants and toddlers were monitored for safe sleep checks, required posted items, feeding schedules, labeled and dated bottles or cups and diaper creams. Small parts, storage of hazardous materials and general safety were monitored. Violations were cited. Please review the violations section for details. Topical ointments were monitored throughout the center and found in compliance There is currently one (1) child enrolled requiring Emergency Medication. All documents, storage and expiration dates were found in compliance. The outdoor play areas were monitored. General safety violations on the play area serving preschoolers were cited. Program records were reviewed and found in compliance. The last fire drill was conducted on October 30, 2025. The last shelter in place was conducted on October 22, 2025. The playground inspections both outdoor play areas and the incident log were in compliance. The EPR plan is currently being updated. The current plan will expire November 26,2024. The ready-to-go file was observed available and in compliance. Staff and Training Worksheets were provided. Six (6) new staff members have been employed since the last annual compliance visit. I reviewed all new employee files and then (10) percent of veteran files. Please see violations section for details regarding items cited. ABCMS was monitored and found in compliance. Ten (10) percent of children’s records were monitored and found in compliance. The following violations were cited today: Violation Number Comment Rule 106 Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection. Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The fire inspection dated 7/31/2025 was received by the Division 10/21/2025. 10A NCAC 09 .0304(a) 807 A safe indoor and outdoor environment was not provided for the children. On the play area serving preschoolers there was rotted wood on a planter boarder, rusty tricycles, and a storage bin full of water. 10A NCAC 09 .0601(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. In Space 2, a Magic Eraser was stored accessible to children in an unlocked cabinet lower than five (5) feet. In Space 8, hand sanitizer was observed by a sink accessible to children. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 1 bags and baggies were stored in cubbies accessible to children. In Space 4 , plastic bags storing clothing was in a cubby accessible to children. .0604(q) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff member hired 5/16/2019 had a medical report on file dated 7/9/2019. One (1) staff member hired 2/17/2025 had a medical assessment on file dated 3/4/2025. 10A NCAC 09 .0701(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved First Aid Certification from National CPR Foundation on file. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One (1) staff member hired 7/14/2025 has an unapproved CPR Certification from National CPR Foundation on file. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. One (1) veteran staff member hired 8/29/05 needed 4 additional on going training hours by 8/29/2025. .1103(a) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Four (4) new staff members received 4.75 hours documented training during first two weeks of employment. .1101(a)(b) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. One (1) veteran staff member hired 5/16/19 did not complete Administration of Medication training. .1103(b) Compliance Statement 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 December 8, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance QRIS/Pathway to the Stars We discussed the pathway, timeline, and resources needed for your rated license. The Division has a timeline for transitioning to current Pathway to the Stars by December 2026. You plan to move forward with Pathway 1. The facility is currently enrolled with Quality Everyday and are receiving technical assistance to prepare for your Rated Licenses Assessments. You requested additional information regarding approved formative assessments. Approved formative assessments can be found on our website here: https://ncchildcare.ncdhhs.gov/Services/Licensing/Star-Rated-License/Curriculum. We discussed that Pathway 1 does not require formative assessments. Staff Records We discussed documenting orientation hours, on-going hours, signatures and importance of dates on all staff files. There is significant improvement in documentation and organization of your staff files since the last annual compliance visit. Storage of Hazardous Materials and Small Parts We discussed developing a formal checklist monitoring tool for your administrative and classroom staff daily. Approved CPR/FA Training Please visit here to get information regarding approved trainers: https://ncchildcare.ncdhhs.gov/Provider/Training-and-Professional-Development/Health-and-Safety-Trainings/Be-a-Smart-Consumer-of-First-Aid-and-CPR-Training NC Rated License Project We discussed that you can train and equip your teachers using the resources for Get Ready for the 3’s / QRIS. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. New Rules Effective July 1, 2025, Now Available Please bookmark Chapter 9 to reference the most current rules effective July 1, 2025. https://ncchildcare.ncdhhs.gov/Portals/0/documents/pdf/C/Chapter_9_Child_Care_Rules_Effective_July_1_2025.pdf?ver=9gQO5ZV3KdVI8BanULluoA%3d%3d Staff WORKS Letters We discussed keeping your staff WORKS Letters up to date and on file. You can access more information here: https://ncchildcare.ncdhhs.gov/Services/DCDEE-WORKS NC FELD Training We discussed utilizing the NC Foundations for Early Learning and Development resource book. I recommend taking the NC FELD training offered through Child Care Resources. The training description and calendar can be accessed here: https://www.childcareresourcesinc.org/training . CCRI will also contract training for your facility if you are interested. MOODLE Staff Orientation We discussed that Moodle now offers orientation and child development training for your staff. Moodle can be accessed here: https://www.dcdee.moodle.nc.gov/ HEALTHY SOCIAL BEHAVIORS PROJECT Supporting teachers to develop pro-social early childhood learning environments that help to prevent suspension and expulsion, as related to challenging behaviors. We are specialists with early childhood education backgrounds who are passionate about empowering teachers to develop learning environments that promote pro-social skills in young children. Our statewide team includes behavior specialists, fidelity coaches, an education specialist, and a project manager covering all 100 counties in North Carolina. The Healthy Social Behaviors project is an initiative of the North Carolina Resource and Referral Council funded by the North Carolina Department of Child Development and Early Education (DCDEE). Contact Stephanie Dreyer, Child Care Resources Inc. 704-376-6697 x 120 | sdreyer@childcareresourcesinc.org for more information. Child Care Resources Technical Assistance Let CCRI come to you! Child Care Resources Inc. provides technical assistance to help you enhance the quality of care you provide for children and families. Our specialists work at your site — with individual classrooms or your entire program — to help you meet short- or long-term goals, maintain higher quality, address your professional development needs, and support program start-up or corrective action requirements. For more information visit: https://www.childcareresourcesinc.org/technical-assistance Technical assistance is guided by a collaboratively developed action plan to accomplish your goals. Support may be episodic or year-long, broadly or narrowly focused. Directors Leadership Network Serving as the director of a child care center means responding to competing needs and demands on your time as you manage the many responsibilities of running a quality program – maintaining compliance with licensing requirements, nurturing children, supporting families, and developing your staff. No wonder you feel like there’s no time for you! Directors Leadership Network powered by CCRI is a way for CCRI to support you as you support one another. As one member stated, “Directors Leadership Network is my opportunity for professional self-care.” If you are looking for a warm and friendly forum to ask questions, share ideas, relieve stress, and receive and offer support among your professional peers, then Directors Leadership Network powered by CCRI is the place for you! For more information, visit https://www.childcareresourcesinc.org/more-resources-1. Reminder Continue to review emails from the Division of Child Development and Early Education (DCDEE) and from your assigned child care consultant. DCDEE Website I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0605 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: 1025-066L Visit Date: 10/14/2025 Number Present: 55 Completed Date: 10/14/2025 Age: From 0 To 4 Total Minutes: 235 Time In: 09:05 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Self Report Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of childcare requirements. A self-report was received by the Division on October 6, 2025. The facility has a compliance history of 84 % prior to today’s visit. Ms. Dora Nettles, Investigations Consultant, accompanied me during today’s visit. Supervision, capacity, ratio, adequate/approved space and general license requirements were monitored during today’s visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. Upon arrival I was greeted by Heather Williamson, Director and Addison Rush, Assistant Director. I stated the reason for the visit. The allegations are as follows: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed An Incident Report did not contain the required information. Ms. Williamson assisted me with a walk through today. I observed personal care routines, active play, outdoor play, and teacher directed activities. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored the outdoor play areas and cited a violation for resilient surfacing. During today’s visit four (4) staff and two (2) administrators were interviewed by Ms. Nettles and Ms. Eddins-Smith. Statements written from each employee interacting with the child on October 3, 2025, were reviewed. The sign-in and sign-out sheets were reviewed. A self-report was submitted on October 6, 2025, from Ms. Rush. On October 7, 2025, the FYI document was received from intake. On October 8, 2025, additional information was submitted to me from intake. We reviewed all documents. The Director stated that there is no video footage available for review. The cameras are not currently operable, and video surveillance is not available. We did review video from a Ring Doorbell dated October 3, 2025, however the video did not contain footage pertinent to the self-report. We reviewed an Incident report sent to me on October 10, 2025. A violation was cited and technical assistance provided. Findings: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed. Three (3) staff interviewed stated a child came into the facility October 3, 2025, upset and unable to be consoled and confirmed that the child had difficulty leaving the parent, holding on to the parent. The parent transitioned the child to the classroom. Two (2) staff stated that a staff member moved the child away by picking her up from behind, under the armpits, from the door area to a carpet in the cozy area in order to keep the child safe from the opening of the classroom door. Two (2) staff interviewed stated that the child transitioned from cozy corner to breakfast and did not eat well. One (1) staff stated that the child did not participate in circle time and that she sat at the table with the child consoling her. The class transitioned to the playground for outdoor play. Two (2) staff members stated that while on the playground the child complained of her arm hurting. An administrator was called. Three (3) staff observed the child’s arm. They did not observe any visible marks or bruise. The parents were notified that the child had been favoring her arm on the playground, had a loose stool and had been crying throughout the morning. All staff interviewed stated that at no time has a child been pulled by the arm. An incident report resulting in injury was not submitted with required information is confirmed. The parents notified the center that medical treatment had been sought, and the child had been diagnosed with a dislocated elbow. The parents did not provide the medical report to the facility. I received an incident report dated October 6, 2025, on Friday, October 10, 2025, at 9:43 am. The document did not include correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. A violation was cited and technical assistance provided. (Cite 1911) The following violations were cited: Violation Number Comment Rule 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The resilient surfacing under the swings and stationary equipment was compacted, had large divots and was not sufficient to meet the critical depth requirements for surfacing under stationary equipment more than 18 inches high. .0605(j) 852 Incident reports were not completed each time a child was injured, it did not include all the information required in rule, it was not signed by the parent and/or it was not maintained in the child's file. The incident report submitted did not include the required information including the correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. .0802 (e) Compliance Statement 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 October 28, 2025, I must receive a written, dated, and signed compliance letter that describes accurately and in detail how and when the violations were corrected as well as monitoring for on-going compliance. Please be aware 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 may be completed. Email the information to: Lisa Eddins-Smith, Child Care Consultant Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance Incident Reports We discussed that incident reports requirements can be reviewed here: 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE. You should complete an incident report to document any situation observed regardless. If you are unable to confirm an injury happened at the facility, submit the report in detail to include all required information. If you are waiting for a parent signature or a parent refuse to sign, please go ahead and send me the report within the required time frame documenting the parent has not signed the report. Complete the report with all details including off-site medical care and any follow-up reported by a parent. Include all witnesses to the incident, the time the parents were notified and any additional information pertinent to the incident. Resilient Surfacing Please review the requirements for resilient surfacing and fall zones in order to meet the requirements. You can find the rule here: 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS. (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or (2) other materials that have 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, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). (k) The depth of the loose surfacing material shall be based on the critical height of the equipment, which is defined as the maximum height that a child may sit, or stand, as follows: (1) equipment with a critical height of 5 feet or less shall have 6 inches of loose surface materials; (2) equipment with a critical height of more than 5 feet, but less than 7 feet, shall have 6 inches of loose surfacing material, except for sand; (3) equipment with a critical height of 7 feet to 10 feet shall have 9 inches of any of the loose surfacing material, except for sand; and (4) when sand is used as a surfacing material for equipment with a critical height of more than 5 feet, 12 inches shall be required. (l) Protective surfacing shall cover the area under and around equipment where a child may fall, referred to as the fall zone. The area for fall zones is as follows: (1) for stationary outdoor equipment used by children under two years of age, the protective surfacing shall extend beyond the external limits of the equipment for a minimum of three feet, except that protective surfacing shall be required at all points of entrance and exit for any structure that has a protective barrier; and (2) for stationary outdoor equipment used by children two years of age or older, the protective surfacing shall extend beyond the external limits of the equipment for six feet; Additionally, I suggest purchasing a rubber mat to place under each swing once you meet critical depth requirements to keep the mulch in place. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0802 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: 1025-066L Visit Date: 10/14/2025 Number Present: 55 Completed Date: 10/14/2025 Age: From 0 To 4 Total Minutes: 235 Time In: 09:05 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Self Report Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of childcare requirements. A self-report was received by the Division on October 6, 2025. The facility has a compliance history of 84 % prior to today’s visit. Ms. Dora Nettles, Investigations Consultant, accompanied me during today’s visit. Supervision, capacity, ratio, adequate/approved space and general license requirements were monitored during today’s visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. Upon arrival I was greeted by Heather Williamson, Director and Addison Rush, Assistant Director. I stated the reason for the visit. The allegations are as follows: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed An Incident Report did not contain the required information. Ms. Williamson assisted me with a walk through today. I observed personal care routines, active play, outdoor play, and teacher directed activities. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored the outdoor play areas and cited a violation for resilient surfacing. During today’s visit four (4) staff and two (2) administrators were interviewed by Ms. Nettles and Ms. Eddins-Smith. Statements written from each employee interacting with the child on October 3, 2025, were reviewed. The sign-in and sign-out sheets were reviewed. A self-report was submitted on October 6, 2025, from Ms. Rush. On October 7, 2025, the FYI document was received from intake. On October 8, 2025, additional information was submitted to me from intake. We reviewed all documents. The Director stated that there is no video footage available for review. The cameras are not currently operable, and video surveillance is not available. We did review video from a Ring Doorbell dated October 3, 2025, however the video did not contain footage pertinent to the self-report. We reviewed an Incident report sent to me on October 10, 2025. A violation was cited and technical assistance provided. Findings: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed. Three (3) staff interviewed stated a child came into the facility October 3, 2025, upset and unable to be consoled and confirmed that the child had difficulty leaving the parent, holding on to the parent. The parent transitioned the child to the classroom. Two (2) staff stated that a staff member moved the child away by picking her up from behind, under the armpits, from the door area to a carpet in the cozy area in order to keep the child safe from the opening of the classroom door. Two (2) staff interviewed stated that the child transitioned from cozy corner to breakfast and did not eat well. One (1) staff stated that the child did not participate in circle time and that she sat at the table with the child consoling her. The class transitioned to the playground for outdoor play. Two (2) staff members stated that while on the playground the child complained of her arm hurting. An administrator was called. Three (3) staff observed the child’s arm. They did not observe any visible marks or bruise. The parents were notified that the child had been favoring her arm on the playground, had a loose stool and had been crying throughout the morning. All staff interviewed stated that at no time has a child been pulled by the arm. An incident report resulting in injury was not submitted with required information is confirmed. The parents notified the center that medical treatment had been sought, and the child had been diagnosed with a dislocated elbow. The parents did not provide the medical report to the facility. I received an incident report dated October 6, 2025, on Friday, October 10, 2025, at 9:43 am. The document did not include correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. A violation was cited and technical assistance provided. (Cite 1911) The following violations were cited: Violation Number Comment Rule 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The resilient surfacing under the swings and stationary equipment was compacted, had large divots and was not sufficient to meet the critical depth requirements for surfacing under stationary equipment more than 18 inches high. .0605(j) 852 Incident reports were not completed each time a child was injured, it did not include all the information required in rule, it was not signed by the parent and/or it was not maintained in the child's file. The incident report submitted did not include the required information including the correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. .0802 (e) Compliance Statement 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 October 28, 2025, I must receive a written, dated, and signed compliance letter that describes accurately and in detail how and when the violations were corrected as well as monitoring for on-going compliance. Please be aware 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 may be completed. Email the information to: Lisa Eddins-Smith, Child Care Consultant Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance Incident Reports We discussed that incident reports requirements can be reviewed here: 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE. You should complete an incident report to document any situation observed regardless. If you are unable to confirm an injury happened at the facility, submit the report in detail to include all required information. If you are waiting for a parent signature or a parent refuse to sign, please go ahead and send me the report within the required time frame documenting the parent has not signed the report. Complete the report with all details including off-site medical care and any follow-up reported by a parent. Include all witnesses to the incident, the time the parents were notified and any additional information pertinent to the incident. Resilient Surfacing Please review the requirements for resilient surfacing and fall zones in order to meet the requirements. You can find the rule here: 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS. (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or (2) other materials that have 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, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). (k) The depth of the loose surfacing material shall be based on the critical height of the equipment, which is defined as the maximum height that a child may sit, or stand, as follows: (1) equipment with a critical height of 5 feet or less shall have 6 inches of loose surface materials; (2) equipment with a critical height of more than 5 feet, but less than 7 feet, shall have 6 inches of loose surfacing material, except for sand; (3) equipment with a critical height of 7 feet to 10 feet shall have 9 inches of any of the loose surfacing material, except for sand; and (4) when sand is used as a surfacing material for equipment with a critical height of more than 5 feet, 12 inches shall be required. (l) Protective surfacing shall cover the area under and around equipment where a child may fall, referred to as the fall zone. The area for fall zones is as follows: (1) for stationary outdoor equipment used by children under two years of age, the protective surfacing shall extend beyond the external limits of the equipment for a minimum of three feet, except that protective surfacing shall be required at all points of entrance and exit for any structure that has a protective barrier; and (2) for stationary outdoor equipment used by children two years of age or older, the protective surfacing shall extend beyond the external limits of the equipment for six feet; Additionally, I suggest purchasing a rubber mat to place under each swing once you meet critical depth requirements to keep the mulch in place. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: 1025-066L Visit Date: 10/14/2025 Number Present: 55 Completed Date: 10/14/2025 Age: From 0 To 4 Total Minutes: 235 Time In: 09:05 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Self Report Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to obtain information regarding alleged violations of childcare requirements. A self-report was received by the Division on October 6, 2025. The facility has a compliance history of 84 % prior to today’s visit. Ms. Dora Nettles, Investigations Consultant, accompanied me during today’s visit. Supervision, capacity, ratio, adequate/approved space and general license requirements were monitored during today’s visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. Upon arrival I was greeted by Heather Williamson, Director and Addison Rush, Assistant Director. I stated the reason for the visit. The allegations are as follows: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed An Incident Report did not contain the required information. Ms. Williamson assisted me with a walk through today. I observed personal care routines, active play, outdoor play, and teacher directed activities. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored the outdoor play areas and cited a violation for resilient surfacing. During today’s visit four (4) staff and two (2) administrators were interviewed by Ms. Nettles and Ms. Eddins-Smith. Statements written from each employee interacting with the child on October 3, 2025, were reviewed. The sign-in and sign-out sheets were reviewed. A self-report was submitted on October 6, 2025, from Ms. Rush. On October 7, 2025, the FYI document was received from intake. On October 8, 2025, additional information was submitted to me from intake. We reviewed all documents. The Director stated that there is no video footage available for review. The cameras are not currently operable, and video surveillance is not available. We did review video from a Ring Doorbell dated October 3, 2025, however the video did not contain footage pertinent to the self-report. We reviewed an Incident report sent to me on October 10, 2025. A violation was cited and technical assistance provided. Findings: A child was not cared for in a nurturing and caring manner resulting in injury is not confirmed. Three (3) staff interviewed stated a child came into the facility October 3, 2025, upset and unable to be consoled and confirmed that the child had difficulty leaving the parent, holding on to the parent. The parent transitioned the child to the classroom. Two (2) staff stated that a staff member moved the child away by picking her up from behind, under the armpits, from the door area to a carpet in the cozy area in order to keep the child safe from the opening of the classroom door. Two (2) staff interviewed stated that the child transitioned from cozy corner to breakfast and did not eat well. One (1) staff stated that the child did not participate in circle time and that she sat at the table with the child consoling her. The class transitioned to the playground for outdoor play. Two (2) staff members stated that while on the playground the child complained of her arm hurting. An administrator was called. Three (3) staff observed the child’s arm. They did not observe any visible marks or bruise. The parents were notified that the child had been favoring her arm on the playground, had a loose stool and had been crying throughout the morning. All staff interviewed stated that at no time has a child been pulled by the arm. An incident report resulting in injury was not submitted with required information is confirmed. The parents notified the center that medical treatment had been sought, and the child had been diagnosed with a dislocated elbow. The parents did not provide the medical report to the facility. I received an incident report dated October 6, 2025, on Friday, October 10, 2025, at 9:43 am. The document did not include correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. A violation was cited and technical assistance provided. (Cite 1911) The following violations were cited: Violation Number Comment Rule 716 All stationary equipment, more than 18 inches high, was not installed over protective surfacing. The resilient surfacing under the swings and stationary equipment was compacted, had large divots and was not sufficient to meet the critical depth requirements for surfacing under stationary equipment more than 18 inches high. .0605(j) 852 Incident reports were not completed each time a child was injured, it did not include all the information required in rule, it was not signed by the parent and/or it was not maintained in the child's file. The incident report submitted did not include the required information including the correct name of the facility, correct date of the incident, medical treatment received, time of incident, location of incident, and all witnesses. The report was not signed by a parent nor was there acknowledgement on the Incident Report from the center stating that the parents refused to sign. .0802 (e) Compliance Statement 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 October 28, 2025, I must receive a written, dated, and signed compliance letter that describes accurately and in detail how and when the violations were corrected as well as monitoring for on-going compliance. Please be aware 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 may be completed. Email the information to: Lisa Eddins-Smith, Child Care Consultant Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Technical Assistance Incident Reports We discussed that incident reports requirements can be reviewed here: 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE. You should complete an incident report to document any situation observed regardless. If you are unable to confirm an injury happened at the facility, submit the report in detail to include all required information. If you are waiting for a parent signature or a parent refuse to sign, please go ahead and send me the report within the required time frame documenting the parent has not signed the report. Complete the report with all details including off-site medical care and any follow-up reported by a parent. Include all witnesses to the incident, the time the parents were notified and any additional information pertinent to the incident. Resilient Surfacing Please review the requirements for resilient surfacing and fall zones in order to meet the requirements. You can find the rule here: 10A NCAC 09 .0605 OUTDOOR LEARNING ENVIRONMENT IN CHILD CARE CENTERS. (j) All stationary outdoor equipment more than 18 inches high shall be installed over protective surfacing. Footings which anchor equipment shall not be exposed. Protective surfacing shall be either: (1) loose surfacing material, including wood mulch, double shredded bark mulch, uniform wood chips, fine sand, coarse sand, and pea gravel, except that pea gravel shall not be used if the area will be used by children under three years of age. Loose surfacing material shall not be installed over concrete; or (2) other materials that have 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, may be used if installed, maintained, and replaced according to the manufacturer's instructions. This standard is incorporated by reference and does include subsequent editions. This standard may be found online at https://www.astm.org/Standards/F1292.htm for a cost of sixty-five dollars ($65.00). (k) The depth of the loose surfacing material shall be based on the critical height of the equipment, which is defined as the maximum height that a child may sit, or stand, as follows: (1) equipment with a critical height of 5 feet or less shall have 6 inches of loose surface materials; (2) equipment with a critical height of more than 5 feet, but less than 7 feet, shall have 6 inches of loose surfacing material, except for sand; (3) equipment with a critical height of 7 feet to 10 feet shall have 9 inches of any of the loose surfacing material, except for sand; and (4) when sand is used as a surfacing material for equipment with a critical height of more than 5 feet, 12 inches shall be required. (l) Protective surfacing shall cover the area under and around equipment where a child may fall, referred to as the fall zone. The area for fall zones is as follows: (1) for stationary outdoor equipment used by children under two years of age, the protective surfacing shall extend beyond the external limits of the equipment for a minimum of three feet, except that protective surfacing shall be required at all points of entrance and exit for any structure that has a protective barrier; and (2) for stationary outdoor equipment used by children two years of age or older, the protective surfacing shall extend beyond the external limits of the equipment for six feet; Additionally, I suggest purchasing a rubber mat to place under each swing once you meet critical depth requirements to keep the mulch in place. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0302 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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 .1106 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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 .2203 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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 09.2200 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110- 90 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110-105 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110-90 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/28/2025 Number Present: 48 Completed Date: 1/28/2025 Age: From 0 To 4 Total Minutes: 128 Time In: 10:52 AM Time Out: 01:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Compliance Follow-Up Announced/Unannounced: Unannounced The purpose of today’s follow-up complaint visit is to verify correction of violations documented during the annual compliance visit January 7, 2025, and Other Visit January 13, 2025. The compliance history was 83 % prior to today’s visit. Supervision, capacity, adequate/approved space and general license requirements were monitored during today’s visit. Upon arrival I was greeted by Addison Rush, Assistant Director, Heather Williamson, Director, and Gerilyn Jones, Professional Development Coordinator. I met with Ms. Williamson and Ms. Rush to discuss the visit. Ms. Williamson and Ms. Rush accompanied on a walk through the facility today. I observed infants and toddlers in personal care routines, tummy time, transition to lunch, and active play. I observed two-year olds in circle time and routines, three-year-olds engaged in teacher directed activity and routines and the 4- and 5-year-old preschool class actively playing in their classroom. Caregivers throughout the center were attending to the needs of the children. I observed caring and nurturing interactions throughout the center. Supervision and staff child ratios were maintained during today’s visit. Each group was observed in approved/adequate space. Permit restrictions were met. I monitored each room for hazardous materials and found in compliance. I monitored each classroom serving children under three for small parts accessible to children. In Space 7, I observed unlocked drawers with plastic and small stickers accessible to children. One two-year-old was present in the classroom. I explained to the teacher and Ms. Williamson that all rules pertaining to children younger than three will need to be in compliance if a two-year-old is present. Ms. Williamson and I met to review the compliance letter emailed January 28, 2025. I reviewed the staff notebooks updated recently by Ms. Jones. Training worksheets have been updated, and all staff have met with Ms. Jones to review the training needed and due dates. The following violations cited January 7, 2025, during the Annual Compliance Visit were monitored for compliance during this visit: # 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. This is a violation of a requirement in G.S. 110-91(6); .0601(b). This item is considered corrected. # 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. This is a violation of a requirement in 10A NCAC 09 .0604(c). This item is considered corrected. # 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. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. This is a violation of a requirement in .2820(b). This item is considered corrected. # 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file. This is a violation of a requirement in .0803(2)(a). This item is considered corrected. # 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. This is a violation of a requirement in .0604(q). A repeat violation was cited today. There were small parts and plastic accessible to children under three years of age in Space 7. This item is not considered corrected. # 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. This is a violation of a requirement in .0605(q). This item is granted extension and is due by March 27, 2025 following a scheduled training for all administrative staff March 26, 2025. # 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. This is a violation of a requirement in .0302(d)(1)(A). This item is considered corrected. # 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023, on file. This is a violation of a requirement in .0701(a). This item is considered corrected. # 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. This is a violation of a requirement in .1101(a). This item is considered corrected. # 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. This is a violation of a requirement in .1102(c). This item is considered corrected. # 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. This is a violation of a requirement in .1102(d). This item is considered corrected. # 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Most veteran staff members had not completed the required number of on-going staff hours. This is a violation of a requirement in .1103(a). This item is considered corrected. # 1054 Documentation of staff's on-going training was not on file and/or was not current. Documentation was not available and not current for most of the staff members. This is a violation of a requirement in 10A NCAC 09 .1106(a). This violation is considered corrected. # 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One 91) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. This is a violation of a requirement in .1102(f). This item is considered corrected. # 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. This is a violation of a requirement in .1101(a)(b). This item is considered corrected. # 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. This is a violation of a requirement in 10A NCAC 09 .0302(d)(2). This item is considered corrected. # 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two (32) staff members did not have a signed statement on file before employment. This is a violation of a requirement in .0608(d)(1-4). This item is considered corrected. # 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. This is a violation of a requirement in .1102(a). This item is considered corrected. # 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. This is a violation of a requirement in .1103(b). This item is considered corrected. The following violation was cited and is a repeat violation: Violation Number Comment Rule 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Space 7, stickers wrapped in plastic labeled not for children under three years old were accessible to children in unlocked drawers. .0604(q) Compliance Statement 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 February 11, 2025, 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. Administrative Action requirements can be found in 10A NCAC 09.2200. ADMINISTRATIVE ACTION We discussed that administrative action will follow due to 16 or more violations being cited during the visit dated January 7, 2025 and a repeat violation cited during today’s visit. Please review SECTION .2200 - ADMINISTRATIVE ACTIONS AND CIVIL PENALTIES for more information. Please review the following rule 10A NCAC 09 .2203 regarding WRITTEN WARNINGS: A written warning, which shall include a corrective action plan, may be issued to an operator in regard to any violation including, but not limited to, these situations: (1) a substantiation of one or more violations as a result of a complaint that do not meet the criteria for a maltreatment finding in accordance with G.S. 110-105.3(b)(3) but for which corrective action is needed; (2) citation of 16 or more violations of separate rules in a single visit where the operator does not meet the criteria of other administrative actions set forth in this Section; or (3) citation of one of the following violations on two consecutive visits: (a) supervision of children; (b) discipline, nurture, or care of children; (c) staff/child ratio; (d) group size; (e) licensed capacity; (f) permit restriction; (g) CPR training; (h) First Aid training; (i) ITS-SIDS training; and (j) criminal record check requirements regarding pre-service and three-year reassessments in accordance with G.S. 110- 90.2(b). We discussed small parts in classrooms serving children under 3. I suggest purchasing a choking tube to test all small parts and establishing a walk through schedule to regularly monitor each room. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety training free of charge. The What’s New tab provides current information that is sent out through blast emails. I encourage owners and all administrators to sign up for NCDCDEE emails. You are interested in applying for a Star-Rated License and attended the training provided for centers January 14, 2025, and CCRI. We discussed the Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed the following informational session which is included in the Raise NC newsletter date 1/24/25. QRIS Modernization Info Session for Educators (Bilingual) The N.C. Child Care Commission and Division of Child Development and Early Education are hosting a bilingual information session for providers on Wednesday January 29 at 6:30 p.m. Join link: https://ncgov.webex.com/ncgov/j.php?MTID=mfeb54371b26f4ee361499fb19deab672 Webinar number: 2420 192 7575 Webinar password: qris (7747 when dialing from a phone or video system) Presented in English with live interpretation in Spanish. Presentado en inglés con interpretación en vivo en español. We discussed the ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. You shared that you have been able to successfully add yourself to the system and have begun the process to add your staff. We discussed your Preservice Administrator Form. You will secure the Owner signature and email the form to me. You gave me the Legal Designee Form signed by Randy Mitchell, Board Director. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0302 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0803 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .1103 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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 .1106 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

G.S. 110-90 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: LISA EDDINS-SMITH Operation Type: Center Case Number: Visit Date: 1/7/2025 Number Present: 51 Completed Date: 1/7/2025 Age: From 0 To 4 Total Minutes: 361 Time In: 09:29 AM Time Out: 03:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable child care requirements for an annual compliance visit. Heather Williamson, Director, and Addison Rush, Assistant Director assisted me with the visit. The facility currently operates with a five-star license, issued August 26, 2020, earning 6 points in the education component, 6 points in the program standards component meeting enhanced space and enhanced ratios and 1 quality point by offering a staff benefits package and approved enhanced policies. The last annual compliance visit was conducted January 19, 2024. The NC Secretary of State website was reviewed on January 7, 2025, and Christ Our Shepherd Ministries was listed as current-active. The compliance history prior to today’s visit is 86%. A sanitation inspection was completed November 21, 2024 with a Superior classification. The last fire inspection was conducted August 2, 2024. A walk-through of the facility was completed today, all indoor areas, outdoor areas , kitchen and gym were monitored. I observed children in the indoor learning environment and found supervision and staff/child ratios to be in compliance. Children throughout the facility were participating in group time, free play in activity areas, transitions, teacher directed art activities and personal care routines. The caregivers were interacting and meeting the developmental needs for each of the children. The teachers and staff used nurturing and caring tones. Program records were reviewed. The last fire drill was conducted December 31, 2024. The last shelter in place was conducted December 31, 2024. The playground inspections for the toddler playground and the incident log were in compliance. The preschool playground inspections did not include the August and September 2024 inspections. The playground inspections were not conducted by a staff member who had completed the Playground Safety Training. The EPR is dated November 26, 2024. Ten percent of children’s records were monitored. Three children did not have updated and current immunization records on file. The Staff and Training Worksheets were on an excel spreadsheet and not complete. Nine new staff members have been employed since the last annual compliance visit and the files for all new staff were not complete. I reviewed the files to observe that all new and veteran staff have a current CBC Qualifying Letter. On-going training has not been calculated and updated for staff. A follow-up visit will be conducted to review staff and training worksheets. See Technical Assistance. The following violations were documented today: Violation Number Comment Rule 721 All equipment and furnishings were not in good repair. A toy lawn mower located on the toddler playground had a broken piece on the top of the engine, creating a sharp area. G.S. 110-91(6); .0601(b) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. In the gym, uncovered outlets were observed near the stage. In Space 3 a plugged in power strip was observed in an unlocked cabinet with uncovered outlets. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. In Space 1, white out and a paint pen was observed in an unlocked drawer. In Space 2 a Magic Eraser was observed in an unlocked drawer. In Space 8, Swiffer pads were observed in an unlocked drawer. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. In Space 2 Nystatin was observed without a physician's signature on file. In Space 3, Mupricion was observed not in the original box and without a physician's signature on file. In Space 8, Albuterol was observed with no Medical Action Plan on file .0803(2)(a) 847 Parent's medication authorization did not include required information. In Spaces 3 and 5 diaper creams were observed without permission to administer forms. 10A NCAC 09 .0803(4)(6-9) 849 Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization. In Space 2, Desitin was observed labeled for a child not enrolled in the classroom and Aquaphor was observed expired 7/2024. .0803(12) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. In Spaces 1, 2, 3, 4, 5, 6, and 8 small items including hair ties, thumb tack, paper clips, and chalk were observed in unlocked drawers accessible to children. In Spaces 1, 3, and 8 plastic was accessible to children. .0604(q) 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. August and September , 2024 inspections were not documented. The inspections were documented by a staff member who has not completed Playground Safety Training. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. Nine (9) staff members did not have an application on file for review. .0302(d)(1)(A) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One (1) staff member had an emergency information form dated August 8, 2023 on file. .0701(a) 1045 New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks. Nine (9) employees did not receive the required hours of orientation within the first six weeks. .1101(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Two (2) employees did not complete First Aid within 90 days of employment. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Two (2) employees did not complete CPR within 90 days of employment. .1102(d) 1052 Staff required to receive on-going training had not completed the required number of hours according to their education and experience. Nineteen (19) staff members had not completed the required number of on-going staff hours. .1103(a) 1054 Documentation of staff's on-going training was not on file and/or was not current . Documentation was not available and not current for twenty-seven (27) veteran staff members. 10A NCAC 09 .1106(a) 1065 Child care providers scheduled to work in the infant room, did not complete ITS-SIDS training within two months of employment or did not complete the training every three years. Child care administrators did not complete the ITS-SIDS training within 90 days of employment and every three years thereafter. One (1) employee scheduled as a floater for the infant room did not have current ITS-SIDS certification. .1102(f) 1067 Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas. Seven (7) employees did not complete the required clock hours within two weeks of employment. .1101(a)(b) 1323 Each child was not immunized as per Article 6 of Chapter 130A and an immunization record was not on file before or within 30 days after admission. Three (3) children did not have an updated immunization record on file. 10A NCAC 09 .0302(d)(2) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. Thirty-two(32)staff members did not have a signed statement on file before employment. .0608(d)(1-4) 1898 Staff did not complete the health and safety training within one year of employment. Six (6) staff members did not complete or have certificates available for review within one year of employment. .1102(a) 1899 Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics. Two (2) staff members did not complete the health and safety training within five years of the previous training. .1103(b) Compliance Statement: 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 21, 2025, 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 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 may be completed. Please email the information to: Lisa.Eddins-Smith@dhhs.nc.gov If you email the compliance letter, it must be sent from the email address on file with DCDEE (this serves as your signature) and the following information must be included: name, position, facility name, and facility ID number. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted or an administrative action may be recommended. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development 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. DCDEE Website: I encourage you to utilize the DCDEE website, https://ncchildcare.ncdhhs.gov/, on a regular basis. All the laws, rules and regulations, item number listing, sanitation requirements, and provider documents can be found on the website. Additionally, there are many resources such as DCDEE Moodle where you can complete health and safety trainings free of charge. The What’s New tab provides current information that is sent out through blast emails. We discussed updating provider forms, so you are using the most current forms available and printing the newest Summary of Law to post. Staff and Training Worksheets: We discussed the staff files and the training worksheets. We visited the NCDCDEE Website together and discussed using the staff and training worksheet provided by the Division and organizing the staff files accordingly. You downloaded the staff and training worksheet. I suggested saving this to your desktop and making this a working document checked monthly. I will make a follow up visit within 7 days to review the updated staff and training worksheets. Plastic and Small Pieces: We discussed monitoring all rooms serving children under three years of age and removing any plastic or small parts accessible to children. I recommend you purchase a choking tube for the facility and read packaging for materials purchased for those classrooms. I suggest locking all drawers on changing tables and in cabinets. See the rule below: 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (q) Plastic bags, toys, toy parts small enough to be swallowed, and materials that can be torn apart, such as foam rubber and styrofoam, shall not be accessible to children under three years of age. However, styrofoam plates and larger pieces of foam rubber may be used for supervised art activities and styrofoam plates may be used for food service. Jump ropes and rubber bands shall not be accessible to children under five years of age without adult supervision. Balloons shall be prohibited for children of all ages. We discussed updating your EPR plan and Ready to Go File. I suggest that you and the Assistant Director attend a training again for better understanding of the requirements and supplies required to be ready in case of an emergency. Feeding Schedules: We discussed obtaining the parent signature on a feeding schedule prior to the child's first day. One new infant did not have a parent signature. The teacher has spoken with the parent and we discussed administration following up. Safe Sleep Charts: We discussed the importance of initial documentation to show a child placed on his/her back. If a child rolls immediately, document that on the next line. Cords: We discussed importance of keeping cords including the telephone cords inaccessible to the children throughout the facility. Mulch: We discussed raking the mulch under around the swing to fill in the compacted areas under the swings. The mulch was frozen today so I was unable to measure it. Annual On-Going Training: We discussed that three of the veteran staff files reviewed today had no or incomplete training documented for 2024. The requirements can be found in 10A NCAC 09 .1103 ON-GOING TRAINING AND PROFESSIONAL DEVELOPMENT of Chapter 9 Child Care Rules and Regulations. I suggest you have a copy of the most up to date child care rules (November 1, 2024) accessible on your desktop and/or in a notebook. There is a current rule review so watch for updates from the NCDCDEE and me regarding changes. We visited the provider forms and documents at our website and downloaded current training sheets for on-going and for health and safety trainings. Get Ready for the 3’s / QRIS: Starting on February 1, 2025, the ECERS-3, ITERS-3, and FCCERS-3—also known as the "3s"—will be used for DCDEE environment rating scale assessments. The DCDEE and the North Carolina Rated License Assessment Project (NCRLAP) are collaboratively working on preparations for the transition to the third editions. These third editions come with a spiral binding at the top, replacing the current revised editions. Visit the NCRLAP’s website, https://www.ncrlap.org/ for more information about updated resources, credit hour trainings, and outreach assessment opportunities to help you become familiar with these tools. For official environment rating scale assessments for a NC Star Rated License, the NCRLAP will use the Revised editions until February 1, 2025. Until February 1, 2025, NCRLAP will use the Revised editions for official environment rating scale assessments for a NC Star Rated License (for new licensees or upon request.) We discussed you attending the following training session: WHO: All Mecklenburg County Owners and Administrators WHAT: Training with Megan Porter from the NCRLAP The Environment Rating Scales (ERS) Third editions- ECERS-3, ITERS-3 WHEN: January 14, 2025, 1:00 pm-3:00 pm WHERE: Child Care Resources Inc. 200-B Regency Executive Park Dr. STE 240 Charlotte, NC 28217 WHY: Exciting news! New Environment Rating Scales have arrived! Starting on February 1, 2025, the ECERS-3, and ITERS-3—also known as the "3s"—will be used for DCDEE assessments. We want you to have all you need to prepare for them. These third editions come with a spiral binding at the top, replacing the current revised editions. ABCMS (Criminal Background System): North Carolina child care administrators can now view and edit their facility’s staff roster in ABCMS, the DCDEE’s criminal background check system. Provider Access to ABCMS allows administrators to: • See the real-time background check status of staff members. • Run a printable report of the staff roster to assist with compliance visits. • See new background check applicants and add to staff roster. As stated in G.S. 110-90.2 & .2703(r) child care operators are to notify the Division of any new child care providers working who were hired or moved into the child care facility within five business days. The process of notifying the Division has changed and is now captured in ABCMS. This change has been in effect since February 2024. Effective immediately, you will need to obtain a Business NCID and complete Provider Portal training in Moodle at https://www.dcdee.moodle.nc.gov/course/view.php?id=119. No action is needed on your part if you have completed the reference training and are currently using the ABCMS Provider Portal to update information regarding new hires or residents. Once the training has been completed and access has been given, you must verify your facility roster to ensure current staff are noted on the roster. This information should be updated in ABCMS in an ongoing basis as staff members are hired and when their employment is terminated. This satisfies the requirement to notify the Division of new child care providers working who were hired or moved into the child care facility within five business days. The compliance of this rule will be monitored during your next visit. Please note, the hard copy of the Change of Information form will no longer be needed or accepted. Should you need assistance please contact the Criminal Background Check Unit at (919) 814-8401 and someone will assist you. At the completion of the visit, this visit summary was printed, reviewed, and a copy was left with you. Thank you for your time today. If you have questions or concerns regarding today’s visit, please contact me at Lisa.Eddins-Smith@dhhs.nc.gov or 980-748-6270. 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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 9/25/2024 Number Present: 53 Completed Date: 9/25/2024 Age: From 0 To 5 Total Minutes: 150 Time In: 02:10 PM Time Out: 04:40 PM Time In: Time Out: List to Use: Center Type Of Visit: Admin Action Follow-Up Lic Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance with applicable child care requirements for an administrative action follow-up visit. A Written Warning was issued by DCDEE to this facility on March 6, 2024. G. Dalton, Interim Director and A. Rush, Assistant Director assisted me with today’s visit. A walk-through of the facility was conducted with Ms. Rush. Children were observed participating in personal care routines and snack. Snack consisted of a banana, graham cracker and water. Staff were observed supervising and interacting with children during activities and leading circle time. The following items were monitored today: supervision, staff/child ratio, group size, licensed capacity, permit restriction, discipline, nurture/care of children, First Aid training, CPR training, ITS-SIDS training, criminal background qualifying letter, staff records, program records, storage of hazardous products/medication and license posted. There has been one new staff member hired since an administrative action follow-up visit was conducted on August 26, 2024. The staff and training worksheets were reviewed to confirm existing staff have current criminal background qualifying letters, First Aid training, CPR training, ITS-SIDS training. The Emergency Drill Log was reviewed today. A lockdown drill was conducted August 26, 2024, and the last fire drill was conducted on September 23, 2024. Playground safety checks were also monitored. Verification that a safety check was completed in August was not on file. The Notice of Administrative Action, cover letter, and Corrective Action Plan was posted near the entrance of the facility. Stipulation #2 of the Corrective Action Plan (CAP) required all staff to participate in Why are Transitions so Hard? Supporting Positive Transitions training. The training was completed on April 18, 2024. I received all required documentation from the training on April 29, 2024. Stipulation #3 of the CAP requires the facility to participate in technical assistance provided by the local resource and referral agency. The facility has participated in technical assistance visits since May 23, 2024. The Assistant Director and former Director met with the Child Development Specialist that provided the technical assistance on July 31, 2024, to review each technical assistance visit and discuss recommendations to include in the facility’s revised supervision policy. The revised policy was received August 28, 2024; however, the policy was not approved. A phone conversation was held with the Interim Director and Assistant Director regarding my suggestions of information to include in the policy and changes needed before approval could be given. Time was given to update the policy with my suggestions. Due to the facility have technology issues for a couple of weeks, I didn’t receive the updated version of the policy until today. During the visit, the policy was reviewed with the Administrators. Changes were made to the policy by the Interim Director. As of today’s date, the policy is approved. Stipulation #5 requires the facility to conduct a staff meeting to review the approved written policy. The facility has two weeks to conduct the meeting. The Interim Director stated that a staff meeting is scheduled for October 10, 2024. Once the meeting has been conducted, you must submit to me documentation of the staff meeting including an attendance roster with printed name, signature of each staff member in attendance, the date, time, length of meeting, and minutes within three days of the meeting. The following violations were observed today. Violation Number Comment Rule 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. A playground safety checklist for August 2024 was not on file. .0605(q) 1030 Application for employment and date of birth was not on file for all staff. An application for a new staff member was not on file. .0302(d)(1)(A) 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 violations documented may impact the compliance history score. The violations documented must be corrected immediately. On or before October 10, 2024, 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 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 may be completed. Mail or email the information to: Kaye Dunlap, Child Care Consultant PO Box 627 Matthews, NC 28106 Kaye.Dunlap@dhhs.nc.gov The following technical assistance was provided. -Playground inspections must be completed monthly by a staff member that has completed Playground Safety training. The inspections must be kept on file for at least a year. A suggestion was made to the Assistant Director to place a reminder in the calendar for each month or to complete the inspection on the same day monthly fire drills are completed. -Applications must be on file the first day of employment for new hires. The new staff member stated an application had been completed however, it could not be located during the visit. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 8/26/2024 Number Present: 49 Completed Date: 8/26/2024 Age: From 0 To 5 Total Minutes: 135 Time In: 10:30 AM Time Out: 12:45 PM Time In: Time Out: List to Use: Center Type Of Visit: Admin Action Follow-Up Lic Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance with applicable child care requirements for an administrative action follow-up visit. A Written Warning was issued by DCDEE to this facility on March 6, 2024. A. Rush, Assistant Director assisted me with today’s visit. A walk-through of the facility was conducted with Ms. Rush. Children were observed participating in personal care routines, free choice of indoor activities and outdoor learning activities, teacher directed activities and circle time. Staff were observed supervising and interacting with children during activities and leading circle time. The following items were monitored today: supervision, staff/child ratio, group size, licensed capacity, permit restriction, discipline, nurture/care of children, First Aid training, CPR training, ITS-SIDS training, criminal background qualifying letter, staff records, program records, storage of hazardous products/medication and license posted. There have been no new staff hired since an administrative action follow-up visit was conducted on July 25, 2024. The staff and training worksheets were reviewed to confirm existing staff have current criminal background qualifying letters, First Aid training, CPR training, ITS-SIDS training. The Emergency Drill Log was reviewed today. A lockdown drill was conducted May 14, 2024, and the last fire drill was conducted on July 30, 2024. Playground safety checks were also monitored. The Notice of Administrative Action, cover letter, and Corrective Action Plan was posted near the entrance of the facility. Stipulation #2 of the Corrective Action Plan (CAP) required all staff to participate in Why are Transitions so Hard? Supporting Positive Transitions training. The training was completed on April 18, 2024. I received all required documentation from the training on April 29, 2024. Stipulation #3 of the CAP requires the facility to participate in technical assistance provided by the local resource and referral agency. The facility has participated in technical assistance visits since May 23, 2024. The Assistant Director and former Director met with the Child Development Specialist that provided the technical assistance on July 31, 2024 to review each technical assistance visit and discuss recommendations to include in the facility’s revised supervision policy. Since the facility, is going through administrative changes the policy is still in the process of being revised however, the Assistant Director stated the revised policy will be emailed to me by Wednesday, August 28, 2024 for approval. Once the revised policy is approved, the Interim Director and Assistant Director will hold a mandatory staff meeting within two weeks of approval to review the new revised policy. Within three days of the meeting, the documentation shall be submitted to me via email. Documentation of the staff meeting shall include an attendance roster with the printed name and signature of each staff member in attendance, the date, time, and length of the meeting, and minutes documenting the information discussed during the meeting. The following violations were observed today. Violation Number Comment Rule 859 Monthly playground inspections were not completed and/or they were not completed by an individual trained in playground safety requirements. Verification that playground inspections were completed for the month of July was not on file. .0605(q) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place or lockdown drill conducted was May 14, 2024. .0604(u);.0302(d)(8) 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 violations documented may impact the compliance history score. The violations documented must be corrected immediately. On or before September 9, 2024, 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 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 may be completed. Mail or email the information to: Kaye Dunlap, Child Care Consultant PO Box 627 Matthews, NC 28106 Kaye.Dunlap@dhhs.nc.gov The following technical assistance was provided. -Playground inspections must be completed monthly by a staff member that has completed Playground Safety training. The inspections must be kept on file for at least a year. A suggestion was made to the Assistant Director to place a reminder in the calendar for each month or to complete the inspection on the same day monthly fire drills are completed. -A shelter-in-place or lockdown drill must be completed every three months. It was explained to the Assistant Director that since the last drill was completed May 14, 2024, another drill was due on or before August 14, 2024. A suggestion was made to also place a reminder in the calendar. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0901 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 7/25/2024 Number Present: 53 Completed Date: 7/25/2024 Age: From 0 To 5 Total Minutes: 145 Time In: 09:40 AM Time Out: 12:05 PM Time In: Time Out: List to Use: Center Type Of Visit: Admin Action Follow-Up Lic Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance with applicable child care requirements for an administrative action follow-up visit. A Written Warning was issued by DCDEE to this facility on March 6, 2024. T. Townsend-Strong assisted me with today’s visit. A walk-through of the facility was conducted with Ms. Townsend-Strong. Children were observed participating in personal care routines, free choice of indoor activities, teacher directed activities and group time. Staff were observed supervising personal care routines, leading group time, and interacting with children during activities. The following items were monitored today: supervision, staff/child ratio, group size, licensed capacity, permit restriction, discipline, nurture/care of children, First Aid training, CPR training, ITS-SIDS training, criminal background qualifying letter, staff records, program records, storage of hazardous products/medication and license posted. There have been two new staff hired since an administrative action follow-up visit was conducted on May 9, 2024. Files for new staff were monitored today. The staff and training worksheets were reviewed to confirm existing staff have current criminal background qualifying letters, First Aid training, CPR training, ITS-SIDS training. The Emergency Drill Log was reviewed today. A lockdown drill was conducted May 14, 2024, and the last fire drill was conducted on June 12, 2024. Playground safety checks were also monitored and occurring monthly as required. The Notice of Administrative Action, cover letter, and Corrective Action Plan was posted near the entrance of the facility. Stipulation #2 of the Corrective Action Plan (CAP) required all staff to participate in Why are Transitions so Hard? Supporting Positive Transitions training. The training was completed on April 18, 2024. I received all required documentation from the training on April 29, 2024. Stipulation #3 of the CAP requires the facility to participate in technical assistance provided by the local resource and referral agency. The facility has participated in nine technical assistance visits since May 23, 2024. Once the technical assistance has been completed, the Director will revise the facility’s supervision policy based on recommendations from the technical assistance received. Once the revised policy is approved, the Director will hold a mandatory staff meeting to review the new revised policy. The following violation was observed today. Violation Number Comment Rule 870 Medications including prescription and non-prescription items were stored above food. In space #7, emergency medications were stored on an open shelf above food such as marshmallows and a single serve container of cereal. 15 A NCAC 18 A.2820(d) The following technical assistance was provided. In space #7, I observed emergency medication being stored above food. A conversation was held with the Lead Teacher regarding storage of prescription and non-prescription medication. It was explained that medications cannot be stored above food. The rule is included for your reference. 15A NCAC 18A .2820 STORAGE (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be kept inaccessible to children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept inaccessible to children when not in use, but are not required to be in locked storage. In space #7, I observed an unopened can of Mountain Dew located on the countertop in the food prep area. I explained to the Lead Teacher that if staff are going to consume food and beverages in the classroom that they must model good nutritional behaviors. The Mountain Dew can was placed in a cabinet. The rule is included for your reference. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (j) Staff shall role model appropriate eating behaviors by consuming only food or beverages that meet the nutritional requirements specified in Paragraph (a) of this Rule in the presence of children in care. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0302 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 6/13/2024 Number Present: 71 Completed Date: 6/13/2024 Age: From 0 To 5 Total Minutes: 200 Time In: 09:30 AM Time Out: 12:50 PM Time In: Time Out: List to Use: Center Type Of Visit: Admin Action Follow-Up Lic Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance with applicable child care requirements for an administrative action follow-up visit. A Written Warning was issued by DCDEE to this facility on March 6, 2024. T. Townsend-Strong assisted me with today’s visit. A walk through of the facility was conducted with the Director. Children were observed participating in personal care routines, free choice of indoor and outdoor activities, teacher directed activities and group time. Staff were observed supervising personal care routines, leading group time, and interacting with children during activities. The following items were monitored today: supervision, staff/child ratio, group size, licensed capacity, permit restriction, discipline, nurture/care of children, First Aid training, CPR training, ITS-SIDS training, criminal background qualifying letter, staff records, program records, storage of hazardous products/medication and license posted. There has been one new staff hired since an administrative action follow-up visit was conducted on May 9, 2024. The new staff member’s file was monitored today. The staff and training worksheets were reviewed to confirm existing staff have current criminal background qualifying letters, First Aid training, CPR training, ITS-SIDS training. The Emergency Drill Log was reviewed today. A lockdown drill was conducted May 14, 2024 and the last fire drill was conducted on June 12, 2024. Playground safety checks were also monitored and occurring monthly as required. Today, the Notice of Administrative Action, cover letter, and Corrective Action Plan was posted near the entrance of the facility. Stipulation #2 of the Corrective Action Plan (CAP) required all staff to participate in Why are Transitions so Hard? Supporting Positive Transitions training. The training was completed on April 18, 2024. I received all required documentation from the training on April 29, 2024. Stipulation #3 of the CAP requires the facility to participate in technical assistance provided by the local resource and referral agency. The facility has participated in six technical assistance visits since May 23, 2024. Once the technical assistance has been completed, the Director will revise the facility’s supervision policy based on recommendations from the technical assistance received. Once the revised policy is approved, the Director will hold a mandatory staff meeting to review the new revised policy. The following violations were observed today. Violation Number Comment Rule 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. In space #7, arrival times for six children had not been recorded on the sign in/out sheet. 10A NCAC 09 .0302(d)(4) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #8, a bottle of sunscreen was stored less than five feet above the floor. The sunscreen did not require being locked however, is required to be stored at least five feet above the floor. 15A NCAC 18A .2820(d) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. Verification was not on file that one new staff member received a negative TB test prior to first day of work. .0701(a) 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One staff member's First Aid training expired June 1, 2024. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One staff member's CPR training expired June 1, 2024. .1102(d) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. In space #8, there was a bottle of sunscreen present with a child's name on it. There was no parent authorization. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) The following technical assistance was provided. -Sunscreens not in an aerosol can are required to be stored at least five feet above the floor. I observed a bottle of sunscreen located in a child’s cubby. The teachers stated that they weren’t aware the sunscreen was in the child’s cubby, and they had not used it. A teacher stated that today was water play day and the parent must have left it there. There was no parent authorization for the sunscreen either. I suggested to the Director to remind the parents that all lotions, sunscreen, bug repellent, etc. be given directly to staff and be accompanied by parent authorization. I recommend the teachers check the personal belongings of each child daily, especially on water play days. -Negative TB tests are required prior to the first day of work for staff. One new staff member had submitted documentation from a doctor’s office however, the documentation didn’t include the staff member’s name or the results. The Director stated that she would send the staff member today to have another test completed. I recommend reviewing all documentation closely to ensure all required information is included. -First Aid and CPR training is required to be renewed by existing staff before the expiration date of the last training. One staff member’s First Aid and CPR expired. The Director stated that she didn’t realize the staff member’s training had expired however, she had already contacted someone to schedule the training for new staff and would include this staff member in the training. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 4/2/2024 Number Present: 79 Completed Date: 4/2/2024 Age: From 0 To 5 Total Minutes: 130 Time In: 12:50 PM Time Out: 03:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Admin Action Follow-Up Lic Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance with applicable child care requirements for an administrative action follow-up visit. A Written Warning was issued by DCDEE to this facility on March 6, 2024. I reviewed the Notice of Administrative Action with the Director, T. Townsend-Strong by phone on March 18, 2024. Today, I met with the Director and Assistant Director, A. Rush. We discussed the requirements for each stipulation in the Corrective Action Plan (CAP) in detail. Stipulation #2 requires all staff to participate in Why are Transitions so Hard? Supporting Positive Transitions training. I received an email March 27, 2024 stating the training is scheduled for April 18, 2024. Stipulation #4 requires the facility to participate in technical assistance provided by the local resource and referral agency. The Director stated today that technical assistance visits would be scheduled after the training is complete. During the visit, I observed the Notice of Administrative Action, cover letter, and Corrective Action Plan posted near the entrance of the facility. A walk through of the facility was conducted with the Director and Assistant Director. Children were observed participating in personal care routines and rest time. Staff were observed supervising personal care routines and rest time. There have been no new staff hired since the annual compliance visit which was conducted on January 19, 2024. The staff and training worksheets were reviewed to confirm existing staff have current criminal background qualifying letters, First Aid training, CPR training, ITS-SIDS training. The facility was also monitored for supervision, discipline, nurture and care of children, staff/child ratio, group size, license capacity, and permit restrictions. The Emergency Drill Log was reviewed today. The last fire drill conducted was March 28, 2024 and a shelter-in-place drill on February 26, 2024. The following violations were observed. Violation Number Comment Rule 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One staff member did not complete First Aid training within 90 days of employment. The staff member's hire date was December 18, 2023. .1102(c) 1049 All staff did not successfully complete certification in CPR training appropriate to the age of the children in care. Verification of staff completion of the CPR course from an approved training organization was not in the staff file. One staff member did not complete CPR training within 90 days of employment date. The staff member's hire date was December 18, 2023. .1102(d) 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 violations documented may impact the compliance history score. The violations documented must be corrected immediately. On or before April 16, 2024, 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 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 may be completed. Mail or email the information to: Kaye Dunlap, Child Care Consultant PO Box 627 Matthews, NC 28106 Kaye.Dunlap@dhhs.nc.gov The following technical assistance was provided: -A conversation was held with the Director and Assistant Director regarding the facility’s supervision policy. As a part of the CAP, the facility is required to revise the current supervision policy. The facility will revise the policy based on suggestions from technical assistance received from the local resource and referral agency. I suggest that the administrators also observe the classrooms at different times of the day, for example during mealtimes, rest time, etc. based on the current policy to see what is working and what needs to be revised. - All staff who provide direct care or accompany children when they are off premises must complete training in First Aid and CPR within 90 days from hire date. The training must include First Aid and CPR appropriate to the ages of children in care and must be from an approved agency. The Director stated that she contacted someone on Monday, April 1, 2024 to schedule a class and is waiting to hear back. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .1801 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: 0124-117L Visit Date: 1/19/2024 Number Present: 71 Completed Date: 1/19/2024 Age: From 0 To 5 Total Minutes: 130 Time In: 01:05 PM Time Out: 03:15 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 child care requirements. The allegation is as follows: There is a concern that a child was left unsupervised in the hallway. Upon arrival I was greeted by the Director, Tina Townsend-Strong. I stated the reason for the visit. This was a “self-report” made by the Director on January 12, 2024. A discussion was held with the Director and Assistant Director, Addison Rush regarding the incident. The Director and Assistant Director stated that approximately 4:30 on January 12, 2024, they were sitting at the front desk of the facility and noticed a child standing in the hallway outside of the child’s classroom which is located near the front desk however a door separates the two spaces. The Assistant Director reported that the child was unharmed, and she took the child back to the classroom where the teacher was continuing to change the other child’s diaper. The door to the classroom was closed and the Teacher was unaware the child had left the classroom. The child was left unattended for approximately three to five minutes. The parent of the child was notified by the Director. A discussion was held with the Teacher present during the supervision incident. She stated that she brought two children one year of age inside from the playground for a diaper change. She stated that one child was standing by her leg and the other was on the changing table while she was removing the child’s clothes. She also reported that a couple of minutes later as she was still changing the child’s diaper that the Assistant Director opened the door from the hallway and the other child was with her. The teacher reported that she didn’t notice the child had left the room, however, that the door leading from the hallway does not close well without force. I reviewed the written warning signed by the Teacher and Director today. The warning includes a description of the incident, and that repeat misconduct/violations would result in a disciplinary action review. The Director also stated that she plans on reviewing the facility’s supervision policy with the staff at the next staff meeting. Based on discussions with staff, the allegation in this report is deemed substantiated. A substantiated complaint may result in an administrative action issued by the Division of Child Development and Early Education. There was one violation cited today. Violation Number Comment Rule 303 Children were not adequately supervised at all times. On January 12, 2024, a child one year of age was left unsupervised in the hallway for approximately three to five minutes. .1801(a)(1-5) 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 violations documented may impact the compliance history score. The violation documented must be corrected immediately. On or before February 2, 2024, I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violation was corrected. Please be aware 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 may be completed. Mail or email the information to: Kaye Dunlap, Child Care Consultant PO Box 627 Matthews, NC 28106 Kaye.Dunlap@dhhs.nc.gov Technical Assistance/General Information: A discussion was held with the Director regarding the classroom door in space #3, she stated that the Teacher submitted a work order to have the doorknob repaired on January 12, 2024 and she notified the facility’s maintenance person on the 12th as well. As a precaution, I suggested adding a bell to hang around the doorknob to ensure the Teachers know when the door is opened. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (1) staff must be positioned in the indoor and outdoor environment to maximize their ability to hear or see the children at all times and render assistance; (2) staff must interact with the children while moving about the indoor or outdoor area; (3) staff must know where each child is located and be aware of the children's activities at all times; (4) staff must provide supervision appropriate to the individual age, needs, and capabilities of each child; and (5) staff must be able to see and hear children aged birth to five years old while the children are eating. All of the conditions in this Paragraph shall apply except when emergencies necessitate that adequate supervision is impossible. Documentation of emergencies shall be maintained and available for review by Division representatives upon request. (b) For groups of children aged two years or older, the staff/child ratio during nap time shall comply with the requirements of this Chapter if at least one person remains in the room, all children are visible to that person, and the total number of required staff are on the premises and within calling distance of the rooms occupied by children. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@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: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: 0124-117L Visit Date: 1/19/2024 Number Present: 71 Completed Date: 1/19/2024 Age: From 0 To 5 Total Minutes: 130 Time In: 01:05 PM Time Out: 03:15 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 child care requirements. The allegation is as follows: There is a concern that a child was left unsupervised in the hallway. Upon arrival I was greeted by the Director, Tina Townsend-Strong. I stated the reason for the visit. This was a “self-report” made by the Director on January 12, 2024. A discussion was held with the Director and Assistant Director, Addison Rush regarding the incident. The Director and Assistant Director stated that approximately 4:30 on January 12, 2024, they were sitting at the front desk of the facility and noticed a child standing in the hallway outside of the child’s classroom which is located near the front desk however a door separates the two spaces. The Assistant Director reported that the child was unharmed, and she took the child back to the classroom where the teacher was continuing to change the other child’s diaper. The door to the classroom was closed and the Teacher was unaware the child had left the classroom. The child was left unattended for approximately three to five minutes. The parent of the child was notified by the Director. A discussion was held with the Teacher present during the supervision incident. She stated that she brought two children one year of age inside from the playground for a diaper change. She stated that one child was standing by her leg and the other was on the changing table while she was removing the child’s clothes. She also reported that a couple of minutes later as she was still changing the child’s diaper that the Assistant Director opened the door from the hallway and the other child was with her. The teacher reported that she didn’t notice the child had left the room, however, that the door leading from the hallway does not close well without force. I reviewed the written warning signed by the Teacher and Director today. The warning includes a description of the incident, and that repeat misconduct/violations would result in a disciplinary action review. The Director also stated that she plans on reviewing the facility’s supervision policy with the staff at the next staff meeting. Based on discussions with staff, the allegation in this report is deemed substantiated. A substantiated complaint may result in an administrative action issued by the Division of Child Development and Early Education. There was one violation cited today. Violation Number Comment Rule 303 Children were not adequately supervised at all times. On January 12, 2024, a child one year of age was left unsupervised in the hallway for approximately three to five minutes. .1801(a)(1-5) 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 violations documented may impact the compliance history score. The violation documented must be corrected immediately. On or before February 2, 2024, I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violation was corrected. Please be aware 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 may be completed. Mail or email the information to: Kaye Dunlap, Child Care Consultant PO Box 627 Matthews, NC 28106 Kaye.Dunlap@dhhs.nc.gov Technical Assistance/General Information: A discussion was held with the Director regarding the classroom door in space #3, she stated that the Teacher submitted a work order to have the doorknob repaired on January 12, 2024 and she notified the facility’s maintenance person on the 12th as well. As a precaution, I suggested adding a bell to hang around the doorknob to ensure the Teachers know when the door is opened. 10A NCAC 09 .1801 SUPERVISION IN CHILD CARE CENTERS (a) Children shall be adequately supervised at all times in child care centers. Adequate supervision shall mean that: (1) staff must be positioned in the indoor and outdoor environment to maximize their ability to hear or see the children at all times and render assistance; (2) staff must interact with the children while moving about the indoor or outdoor area; (3) staff must know where each child is located and be aware of the children's activities at all times; (4) staff must provide supervision appropriate to the individual age, needs, and capabilities of each child; and (5) staff must be able to see and hear children aged birth to five years old while the children are eating. All of the conditions in this Paragraph shall apply except when emergencies necessitate that adequate supervision is impossible. Documentation of emergencies shall be maintained and available for review by Division representatives upon request. (b) For groups of children aged two years or older, the staff/child ratio during nap time shall comply with the requirements of this Chapter if at least one person remains in the room, all children are visible to that person, and the total number of required staff are on the premises and within calling distance of the rooms occupied by children. Thank you for your time today. If you have any questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0701 · Violation

Name of Operation: CHRIST OUR SHEPHERD CHILD CARE Facility ID: 60000927 Consultant: KAYE DUNLAP Operation Type: Center Case Number: Visit Date: 9/18/2023 Number Present: 63 Completed Date: 9/18/2023 Age: From 0 To 4 Total Minutes: 230 Time In: 09:30 AM Time Out: 01:20 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s unannounced visit was to monitor compliance of applicable child care requirements during the routine unannounced visit. Upon arrival, I was greeted by the Director, T. Townsend-Strong. I introduced myself and explained the reason for the visit. A walk through of the facility was conducted with the Director. Children were observed participating in personal care routines, rest time, transitions, circle time, and free choice of indoor and outdoor learning activities. Staff were observed assisting children with personal care routines, circle time and supervising activities. The following items were monitored during today’s visit, supervision, staff/child ratio, first aid, CPR, special training, criminal background checks, ITS-SIDS training, emergency medical care plan, administering of medication, storage of hazardous products, storage of medication, general safety, discipline, adequate/approved space, program records, license posted, permit restrictions. The Staff and Training Worksheets were reviewed to confirm existing staff were current with CPR, First Aid, ITS-SIDS training, and criminal background qualifying letters. Two new staff members have been hired since the annual compliance visit conducted on February 3, 2023. Files for new staff were monitored today. I added two staff members to the worksheets today that were present during my visit. One staff member is a transfer from the facility's sister school and the other is a floater that is shared between the sister school. The last approved fire inspection was conducted on July 19, 2023. The last sanitation inspection was conducted on March 6, 2023, with 25 demerits and an Approved rating. The last fire drill was conducted August 29, 2023, and a shelter-in-place drill August 9, 2023. Outdoor safety inspections were also monitored and occurring monthly as required. There were four violations cited and corrected today. Violation Number Comment Rule 612 Each child's bed, cot, or 2" mat was not individually assigned and identified. In space #1, an infant was observed using a crib that was not labeled with the infant's name on the crib. 15A NCAC 18A .2821(b) & (c) 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. In space #1, a container of Boudreaux's diaper cream was located on the counter near the changing table instead of 5 feet above the floor. 15A NCAC 18A .2820(d) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. One staff member had not updated the health questionnaire annually. .0701(a) 1035 Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually. One staff member did not complete the Emergency Information Form annually. .0701(a) Technical Assistance: A conversation was held with the Director regarding the violations cited. Below is the rule reference for each violation. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS Child care providers, including the director, uncompensated providers, substitute providers, and volunteers shall have an Emergency Information Form, including the name, address, and telephone number of the person to be contacted in case of an emergency, and the responsible party's choice of health care professional on or before the first day of work. The emergency information shall be updated as changes occur and at least annually. All staff, including the director shall have a Health Questionnaire signed by the staff member that indicates that the person is emotionally and physically fit to care for children. Annually following the initial medical statement. 15A NCAC 18A .2821 BEDS, COTS, MATS, AND LINENS (c) Beds, cots, and mats shall be assigned and labeled for use by an individual child and equipped with individual linens. 15A NCAC 18A .2820 STORAGE (c) Non-aerosol sanitizing solutions, approved disinfectants, detergent solutions, hand antiseptics, and hand lotions shall be kept inaccessible to children when not in use, but are not required to be in locked storage. These solutions shall be labeled as sanitizing, disinfecting, or detergent solutions. Hand soap other than that which is in bulk containers is not required to be kept inaccessible to children or in locked storage. Bulk soaps shall be kept inaccessible to children. (d) Medications including prescription and non-prescription items shall be stored in a locked cabinet or other locked container and shall not be stored above food. Designated emergency medications shall be kept inaccessible to children, but are not required to be in locked storage. Non-prescription diaper creams and sunscreen shall be kept inaccessible to children when not in use, but are not required to be in locked storage. Thank you for your time today. If you have questions or concerns, please contact me at 704-594-0152 or by email at kaye.dunlap@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