NC GS 110-90 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/18/2025 Number Present: 27 Completed Date: 9/18/2025 Age: From 5 To 12 Total Minutes: 135 Time In: 01:45 PM Time Out: 04:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by me, Kaitlyn Marshall, Child Care Consultant and also signed by Molly Wooten, Program Coordinator, during the visit. A signed copy of the visit summary was emailed to you. Ms. Wooten was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, CPR/First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, adequate/approved space, program records, license posted. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 9/12/25. Permit type – Four (4) star license issued 5/3/21. Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space, school age only, playground does not meet child care safety standards, children prohibited from being in the kitchen for any purpose. The facility is approved to provide transportation. The last annual compliance visit was conducted on 2/26/25. The last fire drill was practiced on 8/29/25. The last shelter-in-place drill was practiced on 9/2/25. The Emergency Medical Care plan was posted and current. I arrived on the premises of the facility at approximately 1:45pm. I met with Delaney Burke, Administrator, virtually, to review staff files via TEAMS at approximately 2:00pm. There was one (1) new staff. One (1) new staff file and two (2) existing staff files were reviewed. At approximately 2:30pm, I was greeted by M. Wooten. As children arrived at the program, they split into groups. Group 1 transitioned to use the restroom and then ate snack. Snack today consisted of jerky, applesauce, sunflower seeds, and vegetable juice. Group 2 transitioned to the gym. Group 2 participated in group stretches and a staff-led gross motor, team building game. Group 3 transitioned to the trailer where they explored free-choice sculpting with clay. Interactions were positive and supportive. Supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 1048 All staff did not successfully complete certification in First Aid appropriate to the age of children in care. Verification of staff completion of First Aid training from an approved training organization was not in the staff file. One staff, hire date 3/21/25, did not have a First Aid certificate 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 staff, hire date 3/21/25, did not have a CPR certificate on file. .1102(d) Technical assistance was provided as follows: Item #1048 and #1049: One staff, hire date 3/21/25, did not have a CPR/First Aid certificate on file. Staff SH must complete and approved CPR/First Aid training course from an approved source immediately. Once completed, plan to place the certificate in the staff member’s file. Until the training is completed, the staff member cannot be left alone with a group of children. We discussed the staff member can continue to oversee a group of children, but will need to be in the same vicinity of a certified staff member at all times, to help in the event of an emergency. ABCMS Provider Portal: 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. This is a requirement for all child care facilities. If at least one (1) staff member is not linked to your facility at your next visit, a violation may be cited. Achieving Compliance: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 10/2/25. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@ dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall PO Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the restrictions on your license of “playground does not meet child care safety standards” and “children prohibited from being in the kitchen for any purpose” will be removed from your license, according to recent changes in regulations. Soon, we will schedule a meeting to discuss the new Quality Rating and Improvement System (QRIS): Pathways to the Stars. In the meantime, plan to visit https://ncchildcare.ncdhhs.gov/Provider/Licensing/Star-Rated-License/QRIS-Modernization to learn more about the different pathways. Additionally, ensure all staff have updated WORKS letters on file. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any monitoring visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0802 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/5/2024 Number Present: 37 Completed Date: 9/5/2024 Age: From 5 To 12 Total Minutes: 150 Time In: 02:00 PM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Lily Elder, Program Director, during the visit. An electronic signed copy of the visit summary was emailed to you. L. Elder was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, CPR / First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, discipline, adequate / approved space, program records, license posted, and permit restrictions. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety percent (90%) as of 9/3/24. The last fire drill was practiced on 8/30/24. The last emergency drill, lockdown drill, was practiced on 6/6/24. The last fire inspection was approved on 1/31/24. The program’s most recent sanitation inspection was completed on 9/6/23, with nine (9) demerits for a superior rating. The Emergency Medical Care Plan was posted and required updates. There is one (1) new staff. One (1) new staff file was monitored today. Upon arrival I was greeted by Q. McMillan. Children from group 3 were engaged in free choice center play. Children played board games as others arrived. Children then transitioned to outdoor play. Children played soccer, climbed the jungle gym, danced to music, and threw paper airplanes. Children in group 2 were engaged in free choice center play in the gym. Children built small structures with magnatiles and Lincoln logs, played soccer and football, and rolled cars down tracks. Children from group 1 were playing in the gym, then transitioned to eat snack in the cafeteria. Children washed hands and sat down to eat a snack that consisted of jerky, applesauce, vegetable juice, sunflower seeds and milk. Interactions were positive and nurturing. Supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were cited during the visit today: Violation Number Comment Rule 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Prescription medication that was not emergency medical was stored in the unlocked compartment of the backpack. 15A NCAC 18A .2820(d) 1914 The person identified as the person or alternate person responsible for carrying out the emergency medical care plan was not on the premises at all times and/or did not accompany children for off premise activities. The individuals listed as the person responsible and alternates were no longer present at the facility. .0802(b)(1-2) 9995 A violation was found for which there is no item number. Children’s belongings were not kept in individual storage, and were stored on the floor or the bleachers. Technical Assistance provided as follows: Item #1914 The Emergency Medical Care Plan was updated and posted during the visit today. This was corrected. Plan to review the updated plan with site staff to ensure everyone understands their responsibilities. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (b) One person identified as the person or alternate responsible for carrying out the emergency medical care plan and ensuring that appropriate medical care is given shall: (1) be on the premises at all times; and (2) accompany children for off-premises activities. Item #841 The medication was moved to the locked compartment of the backpack. This was corrected. 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. Item #9995 We discussed the laundry baskets that are typically used for backpack storage. These baskets have not been cleaned and re-labeled. We discussed the baskets will be prepared for use and implemented immediately. In your letter of compliance, include a statement that indicates the baskets are being utilized by currently enrolled children. 15A NCAC 18A .2820 STORAGE (f) Individual cubicles, lockers, or coat hooks shall be provided for storage of coats, hats, bags, or other items and accessories. Coat hooks not in individual cubicles or lockers, shall be spaced at least 12 horizontal inches apart. A child's coats, hats, bags, and other items or accessories belonging to a child that are stored using cubicles, lockers, or coat hooks shall not come into contact with stored items belonging to other children. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/19/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: As a reminder, any therapists that visit children during your operating hours must have a Criminal Background Check qualifying letter on file if they are left alone with children. Your sanitation inspection is due by the end of the month. Plan to reach out to Environmental Health if you have not had your visit by mid-month. Plan to conduct a shelter-in-place or lockdown drill by the end of September. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/5/2024 Number Present: 37 Completed Date: 9/5/2024 Age: From 5 To 12 Total Minutes: 150 Time In: 02:00 PM Time Out: 04:30 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during a Routine Unannounced visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Lily Elder, Program Director, during the visit. An electronic signed copy of the visit summary was emailed to you. L. Elder was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, CPR / First Aid, special training, CBC qualification, Emergency Medical Care plan, administration of medication, storage of hazardous products, storage of medication, general safety, discipline, adequate / approved space, program records, license posted, and permit restrictions. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety percent (90%) as of 9/3/24. The last fire drill was practiced on 8/30/24. The last emergency drill, lockdown drill, was practiced on 6/6/24. The last fire inspection was approved on 1/31/24. The program’s most recent sanitation inspection was completed on 9/6/23, with nine (9) demerits for a superior rating. The Emergency Medical Care Plan was posted and required updates. There is one (1) new staff. One (1) new staff file was monitored today. Upon arrival I was greeted by Q. McMillan. Children from group 3 were engaged in free choice center play. Children played board games as others arrived. Children then transitioned to outdoor play. Children played soccer, climbed the jungle gym, danced to music, and threw paper airplanes. Children in group 2 were engaged in free choice center play in the gym. Children built small structures with magnatiles and Lincoln logs, played soccer and football, and rolled cars down tracks. Children from group 1 were playing in the gym, then transitioned to eat snack in the cafeteria. Children washed hands and sat down to eat a snack that consisted of jerky, applesauce, vegetable juice, sunflower seeds and milk. Interactions were positive and nurturing. Supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were cited during the visit today: Violation Number Comment Rule 841 Medications including prescription and non-prescription items were not stored in a locked cabinet or other locked container. Prescription medication that was not emergency medical was stored in the unlocked compartment of the backpack. 15A NCAC 18A .2820(d) 1914 The person identified as the person or alternate person responsible for carrying out the emergency medical care plan was not on the premises at all times and/or did not accompany children for off premise activities. The individuals listed as the person responsible and alternates were no longer present at the facility. .0802(b)(1-2) 9995 A violation was found for which there is no item number. Children’s belongings were not kept in individual storage, and were stored on the floor or the bleachers. Technical Assistance provided as follows: Item #1914 The Emergency Medical Care Plan was updated and posted during the visit today. This was corrected. Plan to review the updated plan with site staff to ensure everyone understands their responsibilities. 10A NCAC 09 .0802 EMERGENCY MEDICAL CARE (b) One person identified as the person or alternate responsible for carrying out the emergency medical care plan and ensuring that appropriate medical care is given shall: (1) be on the premises at all times; and (2) accompany children for off-premises activities. Item #841 The medication was moved to the locked compartment of the backpack. This was corrected. 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. Item #9995 We discussed the laundry baskets that are typically used for backpack storage. These baskets have not been cleaned and re-labeled. We discussed the baskets will be prepared for use and implemented immediately. In your letter of compliance, include a statement that indicates the baskets are being utilized by currently enrolled children. 15A NCAC 18A .2820 STORAGE (f) Individual cubicles, lockers, or coat hooks shall be provided for storage of coats, hats, bags, or other items and accessories. Coat hooks not in individual cubicles or lockers, shall be spaced at least 12 horizontal inches apart. A child's coats, hats, bags, and other items or accessories belonging to a child that are stored using cubicles, lockers, or coat hooks shall not come into contact with stored items belonging to other children. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 9/19/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: As a reminder, any therapists that visit children during your operating hours must have a Criminal Background Check qualifying letter on file if they are left alone with children. Your sanitation inspection is due by the end of the month. Plan to reach out to Environmental Health if you have not had your visit by mid-month. Plan to conduct a shelter-in-place or lockdown drill by the end of September. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .1003 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: 0524-242L Visit Date: 5/20/2024 Number Present: 34 Completed Date: 5/20/2024 Age: From 5 To 10 Total Minutes: 200 Time In: 02:40 PM Time Out: 06:00 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 investigate a complaint received by the Division of Child Development and Early Education (DCDEE) on 5/16/24 and sent to Kaitlyn Marshall, Child Care Consultant, on 5/17/24. The reported concern is regarding safe pick up and drop off procedures. A computerized generated report of today’s visit was unable to be completed due to Regulatory system login issues. A handwritten Visit Summary was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Payton Glisson, Program Coordinator, during the visit. A signed copy of the visit summary was emailed to Delaney Burke, Administrator. P. Glisson was present and available to ask and answer questions throughout the visit today. Applicable child care requirements were monitored today including supervision, safe arrival and departure procedures, staff/child ratio, permit restrictions, approved space and capacity. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety percent (90%) as of 5/17/24. The facility operates on a four (4) star license issued 5/3/21. Restrictions include 1st shift (daytime care), school age only, meets enhanced space, meets enhanced ratios, playground does not meet child care playground safety standards, children prohibited from being in the kitchen for any purpose. Per report, a 10 year old child is dropped off at the facility and is not received at the time of arrival. This has occurred at approximately 3:08 pm on three separate occasions. Upon arrival I observed the child exit bus number 422 and walk to the door leading to hallway of the cafeteria and gym. The child waved at someone through the glass door and P. Glisson immediately opened the door for the child. The bus arrived at 3:27pm. Per provider reports, the staff stand in the doorway of the cafeteria which has a direct view through and additional set of doors leading outside. The doors leading outside have full windows and you are able to see people standing at the door. The provider stated that they are positioned near the cafeteria doors to be able to see the child as they approach the door. From the cafeteria doors, you cannot see the child exit the bus. The safe arrival and departure procedures are posted in a prominent place. The procedures include the following statement: “Upon dismissal, all children will be escorted to the Y program. If a child is involved in another activity, they will be escorted to the Y as soon as the activity dismisses.” This procedure is not being followed for the children riding a bus to the program, as they are not escorted from the bus to the door. If YMCA staff can see the child exit the bus and walk to the door, this will reach compliance as they are able to be supervised upon leaving the bus. Due to statements from the staff that they are positioned in the doorway of the cafeteria which does not offer a direct view of the child getting off the bus and the child is not escorted to the program as stated in procedures, the concerns regarding safe arrival and departure are substantiated. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. A ten year old child who rides bus 422 is not escorted to the facility per safe arrival and departure procedures. The child exited the bus and knocked on the door to be let into the program at approximately 3:27 during the visit today. Staff are positioned to receive the child in the doorway of the cafeteria which does not provide a direct view to the child exiting the bus. .1003(b) Technical Assistance provided as follows: Item #801 A child who rides bus 422 is not escorted to the facility per safe arrival and departure procedures. The child exited the bus and knocked on the door to be let into the program at approximately 3:27 during the visit today. Staff are positioned to receive the child in the doorway of the cafeteria which does not provide a direct view to the child exiting the bus. Work with staff to develop a plan that ensures they will be able to see the child physically exit the bus and walk up to the door of the afterschool program. Alternatively, school/bus staff can walk the child to the door. As a reminder, Assistant Group Leaders who do not have a High School Diploma or equivalent are unable to be left alone with children. 10A NCAC 09 .1003 SAFE PROCEDURES (b) Each center shall establish procedures for pick-up and delivery of children to ensure children are protected from danger and not exposed to risk of harm. These procedures shall be communicated to parents, and a copy shall be posted in the center where they can be seen by the parents. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 6/3/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: I discussed the safe arrival and departure procedures with Melissa Wiedeman, Vice President of Youth Development. We discussed clarifying the procedures to indicate that parents are not required to sign their children in/out of the program. Currently, the procedures include the statement “For the safety of your child, staff cannot accept or release any child before he/she has been signed in or out properly by an adult that is on the child’s application form.” Plan to modify this statement to identify specific situations where this procedure would apply, such as a child joining the afterschool program that was not present at the public school or was not delivered by the DPI bus. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: 0524-242L Visit Date: 5/20/2024 Number Present: 34 Completed Date: 5/20/2024 Age: From 5 To 10 Total Minutes: 200 Time In: 02:40 PM Time Out: 06:00 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 investigate a complaint received by the Division of Child Development and Early Education (DCDEE) on 5/16/24 and sent to Kaitlyn Marshall, Child Care Consultant, on 5/17/24. The reported concern is regarding safe pick up and drop off procedures. A computerized generated report of today’s visit was unable to be completed due to Regulatory system login issues. A handwritten Visit Summary was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Payton Glisson, Program Coordinator, during the visit. A signed copy of the visit summary was emailed to Delaney Burke, Administrator. P. Glisson was present and available to ask and answer questions throughout the visit today. Applicable child care requirements were monitored today including supervision, safe arrival and departure procedures, staff/child ratio, permit restrictions, approved space and capacity. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety percent (90%) as of 5/17/24. The facility operates on a four (4) star license issued 5/3/21. Restrictions include 1st shift (daytime care), school age only, meets enhanced space, meets enhanced ratios, playground does not meet child care playground safety standards, children prohibited from being in the kitchen for any purpose. Per report, a 10 year old child is dropped off at the facility and is not received at the time of arrival. This has occurred at approximately 3:08 pm on three separate occasions. Upon arrival I observed the child exit bus number 422 and walk to the door leading to hallway of the cafeteria and gym. The child waved at someone through the glass door and P. Glisson immediately opened the door for the child. The bus arrived at 3:27pm. Per provider reports, the staff stand in the doorway of the cafeteria which has a direct view through and additional set of doors leading outside. The doors leading outside have full windows and you are able to see people standing at the door. The provider stated that they are positioned near the cafeteria doors to be able to see the child as they approach the door. From the cafeteria doors, you cannot see the child exit the bus. The safe arrival and departure procedures are posted in a prominent place. The procedures include the following statement: “Upon dismissal, all children will be escorted to the Y program. If a child is involved in another activity, they will be escorted to the Y as soon as the activity dismisses.” This procedure is not being followed for the children riding a bus to the program, as they are not escorted from the bus to the door. If YMCA staff can see the child exit the bus and walk to the door, this will reach compliance as they are able to be supervised upon leaving the bus. Due to statements from the staff that they are positioned in the doorway of the cafeteria which does not offer a direct view of the child getting off the bus and the child is not escorted to the program as stated in procedures, the concerns regarding safe arrival and departure are substantiated. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ The following violations were documented during today’s visit: Violation Number Comment Rule 801 Written procedures were not established for pick-up and delivery of children. A ten year old child who rides bus 422 is not escorted to the facility per safe arrival and departure procedures. The child exited the bus and knocked on the door to be let into the program at approximately 3:27 during the visit today. Staff are positioned to receive the child in the doorway of the cafeteria which does not provide a direct view to the child exiting the bus. .1003(b) Technical Assistance provided as follows: Item #801 A child who rides bus 422 is not escorted to the facility per safe arrival and departure procedures. The child exited the bus and knocked on the door to be let into the program at approximately 3:27 during the visit today. Staff are positioned to receive the child in the doorway of the cafeteria which does not provide a direct view to the child exiting the bus. Work with staff to develop a plan that ensures they will be able to see the child physically exit the bus and walk up to the door of the afterschool program. Alternatively, school/bus staff can walk the child to the door. As a reminder, Assistant Group Leaders who do not have a High School Diploma or equivalent are unable to be left alone with children. 10A NCAC 09 .1003 SAFE PROCEDURES (b) Each center shall establish procedures for pick-up and delivery of children to ensure children are protected from danger and not exposed to risk of harm. These procedures shall be communicated to parents, and a copy shall be posted in the center where they can be seen by the parents. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 6/3/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: I discussed the safe arrival and departure procedures with Melissa Wiedeman, Vice President of Youth Development. We discussed clarifying the procedures to indicate that parents are not required to sign their children in/out of the program. Currently, the procedures include the statement “For the safety of your child, staff cannot accept or release any child before he/she has been signed in or out properly by an adult that is on the child’s application form.” Plan to modify this statement to identify specific situations where this procedure would apply, such as a child joining the afterschool program that was not present at the public school or was not delivered by the DPI bus. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0102 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0302 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0304 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0514 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0607 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0701 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0901 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .1102 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .1703 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .2830 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

NC GS 110-90 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 3/6/2024 Number Present: 38 Completed Date: 3/6/2024 Age: From 5 To 11 Total Minutes: 210 Time In: 02:30 PM Time Out: 06:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Peyton Glisson, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. P. Glisson was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition, medication and routine caregiving activities. An annual compliance monitoring checklist for child care centers was used to note the requirements monitored and is attached to the computerized generated visit summary for your records. The center’s compliance history was reviewed with the operator. The program’s compliance history was ninety-five percent (95%) as of 3/4/24. The North Carolina Secretary of State website was viewed prior to today’s visit and the non-profit corporation, The Young Men`s Christian Association of Western North Carolina, Inc., is current/active as of 3/4/24. Permit type – Four (4) Star License issued 5/3/21 Special Services/Restrictions – 1st shift (daytime care), meets enhanced ratios, meets enhanced space. School age only, Playground does not meet child care playground Safety Standards, Children prohibited from being in the kitchen for any purpose. The last annual compliance visit was conducted on 3/24/23. The last fire drill was practiced on 1/22/24. The last shelter-in-place drill was practiced on 11/30/24. The last fire inspection was approved on 1/31/24. The last sanitation inspection was conducted on 9/6/23 with nine (9) demerits for a Superior classification. The Emergency Medical Care plan was posted and current. The Emergency Preparedness and Response plan was updated on 8/19/22. Upon arrival I was greeted by P. Glisson. Children joined in the cafeteria and were then dismissed by groups to go to the bathroom. Group 1 transitioned to eat snack in the cafeteria. After snack, children engaged in free choice play. Children built small structures with magnatiles and connector blocks, read books, engaged in free drawing with colored pencils and markers, folded paper airplanes and explored a marble run. Group 2 transitioned to the gym and sat in a circle for a Y chat. Interactions were positive, children were redirected appropriately as needed. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ Vehicles used for transportation were not on site and were unable to be monitored during the visit today. Monitoring for all YMCA vehicles was conducted on 4/27/23 by Kaoru Eddins, Child Care Consultant. The following violations were documented during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated 2/26/24-3/1/24. 10A NCAC 09 .0901(b) 811 Potentially hazardous items including but not limited to power tools, nails, chemicals, propane stoves, lawn mowers, gasoline, or kerosene were not stored in locked areas, removed from the premises, or made inaccessible to children. A floor buffer with a 24v battery was observed in the cafeteria where children were present. .0604(a) 1032 Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months. One (1) staff, hire date 1/4/24, had a medical report on file dated 1/11/24. 10A NCAC 09 .0701(a) 1033 On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months. One (1) staff, hire date 1/4/24, had a TB test on file dated 1/11/24. .0701(a) 1233 Each employee's personnel file did not contain a signed and dated statement that they received a job description and that they have received personnel and operational policies. One (1) staff, hire date 5/8/21, did not have a signed receipt of operational and personnel policies on file. 10A NCAC 09 .0514(g) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. The last shelter-in-place drill was conducted on 11/30/23. .0604(u);.0302(d)(8) 1824 The trained staff did not review the EPR Plan annually or when information in the plan changed to ensure all information was current. The EPR plan was last updated 8/19/22. .0607(e) 1897 The child care administrator and all staff did not complete the Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. One staff, hire date 5/8/21 did not have a Recognizing and Responding to Suspicions of Child Maltreatment Training certificate on file. .1102(g) Technical assistance was provided as follows: Item # 526 Plan to post the current week’s menu. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Item #811 Work with the school to have the floor buffer moved to a storage area that is inaccessible to children. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (a) In child care centers, potentially hazardous items, including power tools, nails, chemicals, propane stoves, lawn mowers, and gasoline or kerosene, whether or not intended for use by children, shall be stored in locked areas, removed from the premises, or otherwise inaccessible to children. Item # 1032 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. Item #1032 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: Child care providers and uncompensated providers who are not substitute providers or volunteers as defined in 10A NCAC 09 .0102, including the director. Item Requirements: Medical Report A statement signed by a health care professional that indicates that the person is emotionally and physically fit to care for children. Due Date: Prior to employment. When submitted, the medical statement shall not be older than 12 months. Item #1033 In your letter of compliance include a statement that indicates how you will prevent this violation from occurring in the future. 10A NCAC 09 .0701 HEALTH STANDARDS FOR CHILD CARE PROVIDERS, SUBSTITUTE PROVIDERS, VOLUNTEERS, AND UNCOMPENSATED PROVIDERS (a) Health and emergency information shall be obtained for staff members as specified in the chart below: Required for: All staff, including the director and individuals who volunteer more than once per week. Item Requirements: Tuberculin (TB) Test or Screening The results indicating the individual is free of active tuberculosis shall be obtained within the 12 months prior to the date of employment. Due Date: On or before first day of work. Item #1233 Plan to locate and maintain the signed operational and personnel policy acknowledgements in the file for staff P. Glisson. 10A NCAC 09 .0514 OPERATIONAL AND PERSONNEL POLICIES (g) All personnel files of employees hired after April 1, 1999, shall also include a signed and dated statement verifying that the employee received a copy of his or her job description and has reviewed the personnel and operational policies. Item #1811 Plan to conduct a shelter in place or lockdown drill immediately. 10A NCAC 09 .0604 SAFETY REQUIREMENTS FOR CHILD CARE CENTERS (u) A "shelter in place drill" or "lockdown drill" as defined in 10A NCAC 09 .0102 shall be conducted at least every three months and records shall be maintained as required by 10A NCAC 09 .0302(d)(8). Item #1824 Plan to update the EPR plan and place the update copy in your binder. 10A NCAC 09 .0607 EMERGENCY PREPAREDNESS AND RESPONSE IN CHILD CARE CENTERS (e) The trained staff shall review the Emergency Preparedness and Response Plan annually, or when information in the plan changes, to ensure all information is current. Item #1897 Plan to obtain the Recognizing and Responding to Suspicions of Child Maltreatment training certificate and place in staff member S. Carson’s file. 10A NCAC 09 .1102 HEALTH AND SAFETY TRAINING REQUIREMENTS (g) The child care administrator and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. This training shall count toward requirements set forth in Rule .1103 of this Section. Recognizing and Responding to Suspicions of Child Maltreatment training is available at https://www.preventchildabusenc.org/services/trainings-and-professional-development/rrcourse. A certificate of each staff member's completion of this course shall be maintained in the staff member's file in the center. Corrective Action Plan: Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. The violation(s) documented must be corrected immediately. I must receive a written, dated, and signed compliance letter that describes accurately and in detail, how and when the violations were corrected. Please be aware any information submitted by you is legal documentation. If it is determined the information provided in the letter is not true, this may be considered falsification of information. If sufficient information is not received by the due date, a follow-up visit will be conducted. The violations documented above must be corrected immediately. Send me a letter of compliance describing in detail specifically how each violation was corrected and how compliance will be maintained in the future. Include the following: • Facility name • Facility ID# • Date of visit • Violation item number • Statement of compliance I must receive your compliance statement by 3/20/24. Email the compliance letter on signed letterhead or in the email identifying your facility name, ID#, name and position to: kaitlyn.marshall@dhhs.nc.gov or you can mail to: Department of Health and Human Services Division of Child Development and Early Education Attn: Kaitlyn Marshall P.O. Box 19531 Asheville, NC 28815 Please call me at 828-713-8192, or email kaitlyn.marshall@dhhs.nc.gov, if you need assistance. Please note: if mailing the letter of compliance, I must receive it by the due date listed above. You will need to mail a compliance statement three to five days prior to the due date to ensure receipt is within the designated timeline. Failure to correct the violations and send the written statement by the due date listed above may result in an unannounced follow-up visit being conducted. Based on Child Care Rule 10A NCAC 09 Section .2200, the Division of Child Development may take administrative action against the license and/or impose civil penalties based on the failure of the operator to correct any documented violations within the established time period. Consultation is provided as follows: We discussed the routine for children entering the program. Ensure you are maintaining the required staff/child ratio in the cafeteria while children are transitioning to the bathroom. During this transition, plan to keep two (2) staff members with the large group in the cafeteria and one (1) group leader in the hallway with the smaller group of children. A violation was not documented today as the children in both groups were able to be seen and heard through the open door leading to the hallway. We discussed the staff requirements for Group Leader. We discussed that staff who have not completed a high school diploma or equivalency cannot be responsible for a group of children. Staff who have not completed a high school diploma or equivalency shall be considered Assistant Group Leaders until the education requirement is met. The Assistant Group Leaders cannot be responsible for a group of children alone. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. If you elect to change and/or alter any previously approved spaces used by children as indicated on the approved indoor and outdoor floor plan, you will need to contact me within thirty (30) days prior to the change. Failure to notify a DCDEE representative may result in a violation of child care requirements. Child Care Rule 10A NCAC 09 .0304(a) states “Each operator shall schedule and obtain a fire inspection within 12 months of the center's previous fire inspection. The operator shall notify the local fire inspector when it is time for the center's annual fire inspection. The operator shall submit the original of the approved annual fire inspection report to the Division within one week of the inspection visit on the form provided by the Division.” As child care providers, you are a vital part in the prevention and intervention of child maltreatment! You may see potential indicators of maltreatment in the children under your care. Some children may even be more likely to disclose maltreatment to a child care provider than to a family member. It is required that all providers are aware of maltreatment indicators and to report any suspicions of maltreatment. Follow child care rules related to child maltreatment training: 10A NCAC 09 .1102(g) and 10A NCAC 09 .1703(a)(5) states the child care administrator, operator, and all staff members shall complete Recognizing and Responding to Suspicions of Child Maltreatment training within 90 days of employment. Child Care Rule 10A NCAC 09 .2830 MAINTAINING THE STAR RATING (a)A representative of the Division may make announced or unannounced visits to facilities to assess on-going compliance with the requirements of a star rating after it has been issued. Your facility has been placed in cohort 1. You are currently in your Prep Year which will end 6/30/24. Your reassessment year is 7/1/24-6/30/25. A Prep Year assessment was requested 2/23/24. We discussed the importance of ensuring all staff are registered for a WORKS account and are ready to submit transcripts during your reassessment year. It is the center operator’s responsibility to make sure each staff person has registered for a WORKS account, submit an official transcript (if applicable) and apply for a position for evaluation. This should be completed immediately upon hiring or at the latest, by the end of the six-week orientation process. Failure to maintain the same education point level may result in a violation of the above rule reference and may result in a reduction of stars. Child Care Rule 10A NCAC 09 .2830 (c) If employment-related changes occur at a facility that result in the operator not complying with the standards in the Section for the star rating issued, the operator shall correct the noncompliance within 120 days. If the operator does not correct the noncompliance within 120 days, the operator shall notify the Division. It is your responsibility to understand the health and safety requirements in child care rule .1102. If the program is out of compliance in accordance with health and safety requirements, Child Care Development Block Grant (CCDBG), it may affect subsidy funding. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0901 · Violation

Name of Operation: YMCA NORTH BUNCOMBE AFTERSCHOOL Facility ID: 11000675 Consultant: KAITLYN MARSHALL Operation Type: Center Case Number: Visit Date: 9/28/2023 Number Present: 33 Completed Date: 9/28/2023 Age: From 5 To 11 Total Minutes: 140 Time In: 02:40 PM Time Out: 05:00 PM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor compliance during an annual compliance visit. A computerized generated report of today’s visit was completed, reviewed with you, and signed by Kaitlyn Marshall, Child Care Consultant and also signed by Kenzie Ingle, Program Coordinator, during the visit. An electronic signed copy of the visit summary was emailed to you. K. Ingle was present and available to ask and answer questions throughout the visit today. The indoor and outdoor areas were monitored today, including supervision, staff/child ratios, permit restrictions, discipline, nutrition and routine caregiving activities. The center’s compliance history was reviewed with the operator. The program’s compliance history was eighty-six percent (86%) as of 9/25/23. The last fire drill was practiced on 9/21/23. The last emergency drill, lockdown drill, was practiced on 8/31/23. The last fire inspection was approved on 1/31/23. The program’s most recent sanitation inspection was completed on 9/6/23, with nine (9) demerits for a superior rating. The Emergency Medical Care Plan was posted and current. Upon arrival I was greeted by K. Ingle. Children in group 1 transitioned to the cafeteria to eat snack consisting of milk, jerky, sunflower kernels, applesauce, bean and veggie crackers, and vegetable juice blend. Children in group 2 were engaged in outdoor play, swinging, climbing and chasing each other. Children sought support from caregivers for conflict resolution strategies. Interactions were positive and nurturing. Supervision was adequate. I used the Child Care Center Item Number Listing (DCDEE-0357) as a basic monitoring tool to assess compliance with all applicable child care requirements pertinent to this facility. For specific rule references, refer to Chapter 110 General Statues Child Care Facilities, Chapter nine (9) Child Care Rule (10A NCAC 09) and Section 2800 Sanitation of Child Care Center (15A NCAC 18A) for additional information. Updated copies of these rules can be located on our website at https://ncchildcare.ncdhhs.gov/ There are three (3) new staff and two (2) existing staff. The three (3) new staff files were monitored today via TEAMs with Will Deter, Senior Director of Operations- Compliance. One (1) violation was cited during today’s visit: Violation Number Comment Rule 526 Menus for all meals and snacks were not current or posted where easily seen by parents and cook. The posted menu was dated for 9/18/23-9/22/23. 10A NCAC 09 .0901(b) Item #526 Plan to update your posted menu weekly to reflect the current date. This was corrected during the visit today. 10A NCAC 09 .0901 GENERAL NUTRITION REQUIREMENTS (b) When food is prepared by or provided by the center, menus for nutritious meals and snacks shall be planned at least one week in advance. At least one dated copy of the current week's menu shall be posted where it can be seen by parents and food preparation staff when food is prepared or provided by the center. A variety of food shall be included in meals and snacks. Any substitution shall be of comparable food value and shall be recorded on the menu prior to the meal or snack being served. Consultation is provided as follows: Group Leader G. Beaulieu does not have a current CPR/First Aid training certificate but is within her ninety (90) day window. Plan to have a trained staff member accompany G. Beaulieu or be within close calling distance. Staff member S. Carson’s CPR/First Aid expires in October 2023. If you have any questions or concerns regarding the Stabilization Grant, please contact Kaitlyn Marshall, Child Care Consultant, at 828-713-8192 or email kaitlyn.marshall@dhhs.nc.gov. Your facility has been placed in cohort 1. You are currently in your prep year which ends 6/30/24. Your reassessment year is 7/1/24- 6/30/25. Please visit ncrlap.org to learn more about the Prep Year assessment and other valuable resources. Information has been provided to you today regarding the Prep Year assessment in the email containing this visit summary. Please let me know if you would like to move forward with this opportunity. Stay updated with changes and new rule updates by visiting the DCDEE website at https://ncchildcare.ncdhhs.gov/.It is your responsibility to understand the rules and laws that are applicable your program. All rules/laws cannot be verbally reviewed during any licensing visit. Please ask questions if you are having difficulty and would like additional technical assistance. I welcome your questions and want to be a resource for you. We appreciate all you are doing to serve the children and families of NC. If you have questions, please contact me at kaitlyn.marshall@dhhs.nc.gov or 828-713-8192, or Bonnie Mathis, Licensing Supervisor, at bonnie.mathis@dhhs.nc.gov. If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.