10A NCAC 09 .0701 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 8/19/2025 Number Present: 1 Completed Date: 8/19/2025 Age: From 2 To 4 Total Minutes: 145 Time In: 08:25 AM Time Out: 10:50 AM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare facility to monitor compliance with applicable childcare requirements. This visit was conducted with Dawn Poole, Director, and Tiffany Banks, Principal. Your program currently operates with a notice of compliance. The NC Secretary of State website was reviewed on 7/15/25 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 84% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children eating breakfast, engaging in free play, routine activities, and group time. I observed materials and activities that were available to the children in the classrooms. The last annual compliance visit was conducted on 8/22/2024. A sanitation inspection was completed 5/8/2025 with superior classification. The last fire inspection was conducted 6/5/2025. A copy of this inspection was received during the visit. Program records and required postings were monitored. A fire drill was conducted on 8/15/2025. A shelter in place drill was documented on 5/9/2025. An outdoor inspection was documented on 8/15/2025. Staff files and children’s records were monitored per DCDEE procedures. Nutrition requirements were monitored per DCDEE procedures. Storage of hazardous items was monitored today. Storage and administration of medication were monitored. Medication authorization was monitored. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed two air fresheners, two cans of disinfecting spray, and multiple Clorox wipes kept in unlocked cabinets in spaces 106 and 107. .2820(b) 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. During the visit, I observed one (1) employee file that did not contain a medical report. 10A NCAC 09 .0701(a) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 9/2/2025. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit related to violations: • We discussed during the visit that Clorox Wipes, air fresheners, disinfecting sprays, and any hazardous items with multiple warning labels must be kept in locked storage. You moved all items to locked storage during the visit. • We discussed that all employees must have a medical report on file prior to employment. You stated you would have the employee get the medical report on file. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • Make sure you have an emergency drill this month. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 8/19/2025 Number Present: 1 Completed Date: 8/19/2025 Age: From 2 To 4 Total Minutes: 145 Time In: 08:25 AM Time Out: 10:50 AM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare facility to monitor compliance with applicable childcare requirements. This visit was conducted with Dawn Poole, Director, and Tiffany Banks, Principal. Your program currently operates with a notice of compliance. The NC Secretary of State website was reviewed on 7/15/25 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 84% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children eating breakfast, engaging in free play, routine activities, and group time. I observed materials and activities that were available to the children in the classrooms. The last annual compliance visit was conducted on 8/22/2024. A sanitation inspection was completed 5/8/2025 with superior classification. The last fire inspection was conducted 6/5/2025. A copy of this inspection was received during the visit. Program records and required postings were monitored. A fire drill was conducted on 8/15/2025. A shelter in place drill was documented on 5/9/2025. An outdoor inspection was documented on 8/15/2025. Staff files and children’s records were monitored per DCDEE procedures. Nutrition requirements were monitored per DCDEE procedures. Storage of hazardous items was monitored today. Storage and administration of medication were monitored. Medication authorization was monitored. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed two air fresheners, two cans of disinfecting spray, and multiple Clorox wipes kept in unlocked cabinets in spaces 106 and 107. .2820(b) 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. During the visit, I observed one (1) employee file that did not contain a medical report. 10A NCAC 09 .0701(a) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 9/2/2025. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit related to violations: • We discussed during the visit that Clorox Wipes, air fresheners, disinfecting sprays, and any hazardous items with multiple warning labels must be kept in locked storage. You moved all items to locked storage during the visit. • We discussed that all employees must have a medical report on file prior to employment. You stated you would have the employee get the medical report on file. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • Make sure you have an emergency drill this month. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0302 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 1/21/2025 Number Present: 30 Completed Date: 1/21/2025 Age: From 2 To 5 Total Minutes: 130 Time In: 09:50 AM Time Out: 12:00 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 your program for compliance with applicable childcare requirements for a routine unannounced visit. This visit was conducted by Whitney Parker, Childcare Consultant with Emily Pritchard, Director. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 01/14/2025 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 88% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • CPR / First Aid • CBC Qualification • ITS – SIDS • Emergency Medical Care Plan • Administration of Medication • Storage of Hazardous Products • Storage of Medication • General Safety • Discipline • Adequate / Approved Space • Program Records A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children engaging in free play, routine activities, and group time. One new staff was reported at this program. Files for new staff were reviewed. Limited monitoring of staff files was conducted for the purpose of reviewing training regarding CPR/First Aid, EPR, ITS-SIDS, Special Training including Criminal Background Checks. Storage and administration of medication were monitored. Medication authorization was monitored. Storage hazardous items was monitored today. A playground inspection was recorded 12/06/2024. A fire drill was recorded 01/17/2025. A shelter in place drill for the facility was recorded 11/18/2024. The most recent fire inspection was on 05/06/2024. I observed a sanitation inspection was last conducted on 11/20/2024 earning a superior classification. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. During the visit, in space 106, I observed two (2) children that were not signed in upon arrival. 10A NCAC 09 .0302(d)(4) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed a container of Lysol wipes in space 106 stored in an unlocked cabinet. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. During the visit, I observed two Auvi-Q epi-pens stored in a plastic bag not in the original packaging. .0803(2)(a) 898 All electrical appliances were not used in accordance with the manufacturers instruction. Appliances with heating elements, such as bottle warmers, crock pots, curling irons, irons, coffee pots, and/or their cords were accessible to preschool-age children. During the visit, I observed a hot glue gun in space 108 stored in unlocked storage. .0604(e) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 02/04/2025. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit related to violations: • We discussed during the visit that children must be signed in upon arrival to ensure an adequate headcount at all times. The children that were not signed in were signed in during the visit. • We discussed that disinfecting wipes and anything with a heating element (such as a glue gun) are required to be in locked storage to prevent hazards being accessible to children. The Lysol wipes and glue gun were moved to locked storage during the visit. • We discussed that all prescription medications are required to be in the original packaging to ensure the medication is being administered per the physician’s instructions. You contacted the parent during the visit to inquire about the original packaging or written instructions from the physician or pharmacist. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • The process of notifying the Division of new employees 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 childcare 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. • Please let me know if you will be open for the summer whenever you all make a decision. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 1/21/2025 Number Present: 30 Completed Date: 1/21/2025 Age: From 2 To 5 Total Minutes: 130 Time In: 09:50 AM Time Out: 12:00 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 your program for compliance with applicable childcare requirements for a routine unannounced visit. This visit was conducted by Whitney Parker, Childcare Consultant with Emily Pritchard, Director. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 01/14/2025 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 88% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • CPR / First Aid • CBC Qualification • ITS – SIDS • Emergency Medical Care Plan • Administration of Medication • Storage of Hazardous Products • Storage of Medication • General Safety • Discipline • Adequate / Approved Space • Program Records A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children engaging in free play, routine activities, and group time. One new staff was reported at this program. Files for new staff were reviewed. Limited monitoring of staff files was conducted for the purpose of reviewing training regarding CPR/First Aid, EPR, ITS-SIDS, Special Training including Criminal Background Checks. Storage and administration of medication were monitored. Medication authorization was monitored. Storage hazardous items was monitored today. A playground inspection was recorded 12/06/2024. A fire drill was recorded 01/17/2025. A shelter in place drill for the facility was recorded 11/18/2024. The most recent fire inspection was on 05/06/2024. I observed a sanitation inspection was last conducted on 11/20/2024 earning a superior classification. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 125 Daily records of arrival and departure times for children enrolled at the center were not maintained as children arrive and depart and/or were not made available for review. During the visit, in space 106, I observed two (2) children that were not signed in upon arrival. 10A NCAC 09 .0302(d)(4) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed a container of Lysol wipes in space 106 stored in an unlocked cabinet. .2820(b) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. During the visit, I observed two Auvi-Q epi-pens stored in a plastic bag not in the original packaging. .0803(2)(a) 898 All electrical appliances were not used in accordance with the manufacturers instruction. Appliances with heating elements, such as bottle warmers, crock pots, curling irons, irons, coffee pots, and/or their cords were accessible to preschool-age children. During the visit, I observed a hot glue gun in space 108 stored in unlocked storage. .0604(e) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 02/04/2025. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit related to violations: • We discussed during the visit that children must be signed in upon arrival to ensure an adequate headcount at all times. The children that were not signed in were signed in during the visit. • We discussed that disinfecting wipes and anything with a heating element (such as a glue gun) are required to be in locked storage to prevent hazards being accessible to children. The Lysol wipes and glue gun were moved to locked storage during the visit. • We discussed that all prescription medications are required to be in the original packaging to ensure the medication is being administered per the physician’s instructions. You contacted the parent during the visit to inquire about the original packaging or written instructions from the physician or pharmacist. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • The process of notifying the Division of new employees 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 childcare 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. • Please let me know if you will be open for the summer whenever you all make a decision. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 8/22/2024 Number Present: 26 Completed Date: 8/22/2024 Age: From 2 To 5 Total Minutes: 205 Time In: 08:50 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare center to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant, and Emily Lamquaye, Childcare Consultant, with Emily Pritchard, Director. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 7/15/24 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 90% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children eating morning snack, engaging in free play, routine activities, and group time. I observed materials and activities that were available to the children in the classrooms. The last annual compliance visit was conducted on 9/27/23. A sanitation inspection was completed 5/2/24 with a superior classification. The last fire inspection was conducted 5/6/24. Program records and required postings were monitored. A fire drill was conducted on 08/16/24. A shelter in place drill was documented on 08/20/24. An outdoor inspection was documented on 08/16/2024. Staff files and children’s records were monitored per DCDEE procedures. Nutrition requirements were monitored per DCDEE procedures. Storage of hazardous items was monitored today. Hazardous items were stored in locked cabinets and closets. No medications were observed nor reported. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 115 A summary of the NC Child Care Law was not posted in a prominent place in the center. During the visit, I did not observe a posted summary of the NC Child Care Law in a prominent place. G.S. 110-102 615 Beds, cots and mats were not in good repair, properly handled, stored, or clean and sanitized between users. During the visit, I observed mats that were stored with sheets on them that were touching other sheets used by other children. 15A NCAC 18A .2821(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. During the visit, I observed one outlet in the cafeteria that was not covered. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed a bottle of hand sanitizer stored on a shelf approximately four vertical feet high. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. During the visit, I observed several plastic shopping bags stored under a changing table in space 106, the classroom designated for two year old children. .0604(q) 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. All violations cited today were corrected during the visit. A compliance letter is not due at this time. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: • We discussed G.S. 110-102. The childcare summary of the law must be posted in a prominent place in the center. It is important that families have access to this at all times. You posted a copy of the summary of the law during the visit. • We discussed rule .0604(c). Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets. For this reason, all electrical outlets, including those on power strips, not in use that are in areas accessible to children must be protected with a safety plug or a tamper-resistant electrical outlet. An open outlet was observed in the cafeteria space. You covered the outlet during the visit. • We discussed rule 15A NCAC 18A.2820(b). Hazardous items must be stored inaccessible to young children. Hand sanitizer must be stored at least five vertical feet. You moved the hand sanitizer to at least five vertical feet during the visit. • We discussed rule .0604(q). Plastic bags pose a choking hazard to young children. Plastic bags must be kept inaccessible to children under three years of age. You moved the plastic bags that were being stored under the changing table in the classroom designated for two-year-old children to inaccessible storage during the visit. • We discussed rule 15A NCAC 18A.2821(a). Linens must be stored so that they are not touching other linens used by other children. This is to prevent potential spread of illness and diseases. You stored the linens separately during the visit. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • Make sure the medical file is stored separately form the personnel files. They have to be stored behind the personnel folder. • Make sure you complete the EPR template as soon as possible. Email me a copy of the template once you finish. • The licensed children cannot use the large structure on the school-age playground until the manufacturer instructions are located and the age requirements are verified. • Make sure you have a medical report on file for each child within thirty days of enrollment. • Prior to children using the art room, make sure you cover the outlets and lock any cabinets that have hazardous supplies including anything with multiple warning labels. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

G.S. 110-102 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 8/22/2024 Number Present: 26 Completed Date: 8/22/2024 Age: From 2 To 5 Total Minutes: 205 Time In: 08:50 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare center to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant, and Emily Lamquaye, Childcare Consultant, with Emily Pritchard, Director. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 7/15/24 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 90% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children eating morning snack, engaging in free play, routine activities, and group time. I observed materials and activities that were available to the children in the classrooms. The last annual compliance visit was conducted on 9/27/23. A sanitation inspection was completed 5/2/24 with a superior classification. The last fire inspection was conducted 5/6/24. Program records and required postings were monitored. A fire drill was conducted on 08/16/24. A shelter in place drill was documented on 08/20/24. An outdoor inspection was documented on 08/16/2024. Staff files and children’s records were monitored per DCDEE procedures. Nutrition requirements were monitored per DCDEE procedures. Storage of hazardous items was monitored today. Hazardous items were stored in locked cabinets and closets. No medications were observed nor reported. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 115 A summary of the NC Child Care Law was not posted in a prominent place in the center. During the visit, I did not observe a posted summary of the NC Child Care Law in a prominent place. G.S. 110-102 615 Beds, cots and mats were not in good repair, properly handled, stored, or clean and sanitized between users. During the visit, I observed mats that were stored with sheets on them that were touching other sheets used by other children. 15A NCAC 18A .2821(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. During the visit, I observed one outlet in the cafeteria that was not covered. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed a bottle of hand sanitizer stored on a shelf approximately four vertical feet high. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. During the visit, I observed several plastic shopping bags stored under a changing table in space 106, the classroom designated for two year old children. .0604(q) 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. All violations cited today were corrected during the visit. A compliance letter is not due at this time. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: • We discussed G.S. 110-102. The childcare summary of the law must be posted in a prominent place in the center. It is important that families have access to this at all times. You posted a copy of the summary of the law during the visit. • We discussed rule .0604(c). Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets. For this reason, all electrical outlets, including those on power strips, not in use that are in areas accessible to children must be protected with a safety plug or a tamper-resistant electrical outlet. An open outlet was observed in the cafeteria space. You covered the outlet during the visit. • We discussed rule 15A NCAC 18A.2820(b). Hazardous items must be stored inaccessible to young children. Hand sanitizer must be stored at least five vertical feet. You moved the hand sanitizer to at least five vertical feet during the visit. • We discussed rule .0604(q). Plastic bags pose a choking hazard to young children. Plastic bags must be kept inaccessible to children under three years of age. You moved the plastic bags that were being stored under the changing table in the classroom designated for two-year-old children to inaccessible storage during the visit. • We discussed rule 15A NCAC 18A.2821(a). Linens must be stored so that they are not touching other linens used by other children. This is to prevent potential spread of illness and diseases. You stored the linens separately during the visit. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • Make sure the medical file is stored separately form the personnel files. They have to be stored behind the personnel folder. • Make sure you complete the EPR template as soon as possible. Email me a copy of the template once you finish. • The licensed children cannot use the large structure on the school-age playground until the manufacturer instructions are located and the age requirements are verified. • Make sure you have a medical report on file for each child within thirty days of enrollment. • Prior to children using the art room, make sure you cover the outlets and lock any cabinets that have hazardous supplies including anything with multiple warning labels. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

NC GS 110-90 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 8/22/2024 Number Present: 26 Completed Date: 8/22/2024 Age: From 2 To 5 Total Minutes: 205 Time In: 08:50 AM Time Out: 12:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare center to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant, and Emily Lamquaye, Childcare Consultant, with Emily Pritchard, Director. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 7/15/24 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 90% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children eating morning snack, engaging in free play, routine activities, and group time. I observed materials and activities that were available to the children in the classrooms. The last annual compliance visit was conducted on 9/27/23. A sanitation inspection was completed 5/2/24 with a superior classification. The last fire inspection was conducted 5/6/24. Program records and required postings were monitored. A fire drill was conducted on 08/16/24. A shelter in place drill was documented on 08/20/24. An outdoor inspection was documented on 08/16/2024. Staff files and children’s records were monitored per DCDEE procedures. Nutrition requirements were monitored per DCDEE procedures. Storage of hazardous items was monitored today. Hazardous items were stored in locked cabinets and closets. No medications were observed nor reported. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 115 A summary of the NC Child Care Law was not posted in a prominent place in the center. During the visit, I did not observe a posted summary of the NC Child Care Law in a prominent place. G.S. 110-102 615 Beds, cots and mats were not in good repair, properly handled, stored, or clean and sanitized between users. During the visit, I observed mats that were stored with sheets on them that were touching other sheets used by other children. 15A NCAC 18A .2821(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. During the visit, I observed one outlet in the cafeteria that was not covered. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. During the visit, I observed a bottle of hand sanitizer stored on a shelf approximately four vertical feet high. .2820(b) 858 Plastic bags, materials that could be torn apart and toy parts small enough to be swallowed were accessible to children under three years of age. During the visit, I observed several plastic shopping bags stored under a changing table in space 106, the classroom designated for two year old children. .0604(q) 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. All violations cited today were corrected during the visit. A compliance letter is not due at this time. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: • We discussed G.S. 110-102. The childcare summary of the law must be posted in a prominent place in the center. It is important that families have access to this at all times. You posted a copy of the summary of the law during the visit. • We discussed rule .0604(c). Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets. For this reason, all electrical outlets, including those on power strips, not in use that are in areas accessible to children must be protected with a safety plug or a tamper-resistant electrical outlet. An open outlet was observed in the cafeteria space. You covered the outlet during the visit. • We discussed rule 15A NCAC 18A.2820(b). Hazardous items must be stored inaccessible to young children. Hand sanitizer must be stored at least five vertical feet. You moved the hand sanitizer to at least five vertical feet during the visit. • We discussed rule .0604(q). Plastic bags pose a choking hazard to young children. Plastic bags must be kept inaccessible to children under three years of age. You moved the plastic bags that were being stored under the changing table in the classroom designated for two-year-old children to inaccessible storage during the visit. • We discussed rule 15A NCAC 18A.2821(a). Linens must be stored so that they are not touching other linens used by other children. This is to prevent potential spread of illness and diseases. You stored the linens separately during the visit. Additional Information/Consultation: • You must notify your consultant 30 days prior to changing the ownership status of your facility. • Make sure the medical file is stored separately form the personnel files. They have to be stored behind the personnel folder. • Make sure you complete the EPR template as soon as possible. Email me a copy of the template once you finish. • The licensed children cannot use the large structure on the school-age playground until the manufacturer instructions are located and the age requirements are verified. • Make sure you have a medical report on file for each child within thirty days of enrollment. • Prior to children using the art room, make sure you cover the outlets and lock any cabinets that have hazardous supplies including anything with multiple warning labels. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0604 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 3/20/2024 Number Present: 35 Completed Date: 3/20/2024 Age: From 2 To 5 Total Minutes: 105 Time In: 08:30 AM Time Out: 10:15 AM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for a routine unannounced visit. This visit was conducted by Whitney Parker, Childcare Consultant with Tiffany Banks, Principal. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 03/20/2024 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 91% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • CPR / First Aid • CBC Qualification • ITS – SIDS • Emergency Medical Care Plan • Administration of Medication • Storage of Hazardous Products • Storage of Medication • General Safety • Discipline • Adequate / Approved Space • Program Records A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Seven classrooms are licensed for childcare at this facility. Spaces 101 and 109 were not in use by preschool aged children in the licensed childcare facility. These classrooms were not fully monitored as they are not being used by the childcare facility at this time. Three classrooms, spaces 106, 107, and 108 were in use by preschool aged children during today’s visit and monitored per DCDEE procedures. Children were also observed in the licensed cafeteria having morning snack. This space was monitored during today’s visit. Space 100 is used an a multipurpose room by preschool aged children and was monitored during the visit. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children engaging in free play, routine activities, and eating morning snack. Three new staff were reported at this program. Files for new staff were reviewed. Limited monitoring of staff files was conducted for the purpose of reviewing training regarding CPR/First Aid, EPR, Special Training, and Criminal Background Checks. Storage and administration of medication were monitored. Medication authorization was monitored. Storage hazardous items was monitored today. Hazardous items are stored in locked cabinets. A playground inspection was recorded 03/05/2024. A fire drill was recorded 03/08/2024. A shelter in place drill for the facility was recorded 03/13/2024. The most recent fire inspection was on 10/11/2023. I received a copy of this inspection during today's visit. I observed a sanitation inspection was completed 08/30/2023 with a superior classification. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. I observed one outlet that was not covered using a safety plug in space 100. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. I observed a can on Lysol stored in an unlocked cabinet that was five vertical feet high in space 106. .2820(b) 853 Incident logs were not completed and maintained as required. The incident log was not able to be located during the visit. .0802(g)(1-6) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 04/03/2024. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: •We discussed rule .0802(g)(1-6) and that incident reports should be recorded on a log as they occur and that the log must be kept current and maintained on file for review. Additional Information/Consultation: •You must notify your consultant 30 days prior to changing the ownership status of your facility. •On 02/21/2024, I emailed Ms. Pritchard a document regarding required Lead and Asbestos Testing. Ms. Banks confirmed during today’s visit that the email was received and provided information that Ms. Pritchard completed the training on 12/22/2023. Ms. Pritchard received an email on 02/23/2024 stating that the survey was under review. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

NC GS 110-90 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 3/20/2024 Number Present: 35 Completed Date: 3/20/2024 Age: From 2 To 5 Total Minutes: 105 Time In: 08:30 AM Time Out: 10:15 AM Time In: Time Out: List to Use: Center Type Of Visit: Routine Unannounced Announced/Unannounced: Unannounced The purpose of today’s visit was to monitor your program for compliance with applicable childcare requirements for a routine unannounced visit. This visit was conducted by Whitney Parker, Childcare Consultant with Tiffany Banks, Principal. Your program currently operates with a Notice of Compliance. The NC Secretary of State website was reviewed on 03/20/2024 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 91% prior to today’s visit. All programs are required to maintain at least 75% compliance. Today, the following items were monitored: • Supervision • Staff / Child Ratio • CPR / First Aid • CBC Qualification • ITS – SIDS • Emergency Medical Care Plan • Administration of Medication • Storage of Hazardous Products • Storage of Medication • General Safety • Discipline • Adequate / Approved Space • Program Records A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Seven classrooms are licensed for childcare at this facility. Spaces 101 and 109 were not in use by preschool aged children in the licensed childcare facility. These classrooms were not fully monitored as they are not being used by the childcare facility at this time. Three classrooms, spaces 106, 107, and 108 were in use by preschool aged children during today’s visit and monitored per DCDEE procedures. Children were also observed in the licensed cafeteria having morning snack. This space was monitored during today’s visit. Space 100 is used an a multipurpose room by preschool aged children and was monitored during the visit. Staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed staff/child interactions today. I observed children engaging in free play, routine activities, and eating morning snack. Three new staff were reported at this program. Files for new staff were reviewed. Limited monitoring of staff files was conducted for the purpose of reviewing training regarding CPR/First Aid, EPR, Special Training, and Criminal Background Checks. Storage and administration of medication were monitored. Medication authorization was monitored. Storage hazardous items was monitored today. Hazardous items are stored in locked cabinets. A playground inspection was recorded 03/05/2024. A fire drill was recorded 03/08/2024. A shelter in place drill for the facility was recorded 03/13/2024. The most recent fire inspection was on 10/11/2023. I received a copy of this inspection during today's visit. I observed a sanitation inspection was completed 08/30/2023 with a superior classification. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. I observed one outlet that was not covered using a safety plug in space 100. 10A NCAC 09 .0604(c) 840 All corrosive agents, pesticides, bleaches, detergents, cleansers, polishes, any product which is under pressure in an aerosol dispenser, and any substance which may be hazardous to a child if ingested, inhaled, or handled were not stored in a locked room or cabinet. I observed a can on Lysol stored in an unlocked cabinet that was five vertical feet high in space 106. .2820(b) 853 Incident logs were not completed and maintained as required. The incident log was not able to be located during the visit. .0802(g)(1-6) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 04/03/2024. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. Technical assistance discussed during today’s visit: •We discussed rule .0802(g)(1-6) and that incident reports should be recorded on a log as they occur and that the log must be kept current and maintained on file for review. Additional Information/Consultation: •You must notify your consultant 30 days prior to changing the ownership status of your facility. •On 02/21/2024, I emailed Ms. Pritchard a document regarding required Lead and Asbestos Testing. Ms. Banks confirmed during today’s visit that the email was received and provided information that Ms. Pritchard completed the training on 12/22/2023. Ms. Pritchard received an email on 02/23/2024 stating that the survey was under review. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

10A NCAC 09 .0601 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 9/27/2023 Number Present: 41 Completed Date: 9/27/2023 Age: From 2 To 5 Total Minutes: 315 Time In: 09:00 AM Time Out: 02:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare facility to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant with Emily Pritchard, Director, and Tiffany Banks, Principal. Your program currently operates with a Notice of Compliance with restrictions of 1st Shift (daytime care) and children under 3 years old in rooms with direct exits only. The NC Secretary of State website was reviewed on 09/26/2023 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 92% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Seven classrooms are licensed for space for childcare at this facility. Spaces 100, 101, and 109 were not in use by preschool aged children in the licensed childcare facility. These classrooms were not fully monitored as they are not being used by the childcare facility at this time. Three classrooms, spaces 106, 107, and 108 were in use by preschool aged children during today’s visit and monitored per DCDEE procedures. Children were also observed in the licensed cafeteria having morning snacks. This space was monitored during today’s visit. During the walkthrough, I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. I observed two outlets that did not have safety plugs in space 106. Upon arrival, staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed positive interactions today. I observed children engaging in free play, routine activities, and group time. I observed developmentally appropriate materials and activities were available to the children in the classrooms. The last annual compliance visit was conducted on 10/24/2022. A sanitation inspection was completed 08/30/2023 with a superior classification. You provided me with a copy of this inspection during today’s visit. The last fire inspection was conducted 10/17/2022. Program records and required postings were monitored. A fire drill was conducted on 09/27/2023. A shelter in place drill was documented on 04/18/2023. An emergency drill was due in July 2023, and one was not observed. An outdoor inspection was documented on 09/14/2023. I did not observe a playground inspection for the month of August 2023. Staff files and children’s records were monitored per DCDEE procedures. I observed one employee file that did not have an annual staff professional development plan. I observed one employee file that did not have a current health questionnaire. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. I observed one employee file that did not complete six hours of orientation within the first two weeks of employment. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. Storage of hazardous items was monitored today. Hazardous items are stored in locked cabinets. Storage and administration of medication were monitored. Medication authorization was monitored. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. I observed one inhaler that did not include a medication authorization. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 807 A safe indoor and outdoor environment was not provided for the children. There were no safety concerns outdoors. I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. 10A NCAC 09 .0601(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. I observed two outlets that did not have safety plugs in space 106. 10A NCAC 09 .0604(c) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. .0803(2)(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. I observed one employee file that did not have a current health questionnaire. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. An emergency drill was due in July 2023, and one was not observed. .0604(u);.0302(d)(8) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. .0801(b) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. .0608(d)(1-4) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. I observed one inhaler that did not include a medication authorization. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 10/11/2023. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. During today’s visit, we discussed the possibility of using space 100 for music and movement. This is a licensed space and could be used as an auxiliary space. However, prior to using this space, be sure that you have covered all outlets with safety plugs and make sure that all cabinets do not contain items that should be in locked storage. We also discussed the removal of space 101 and/or 109 from your license. If you do not think you will ever use these spaces for the licensed childcare center and you wish to remove them from your license, reach out to me via email and we will begin the process. During today’s visit, we discussed possibly licensing the chapel and gymnasium as auxiliary spaces. You stated you would like to visit the chapel for approximately twenty to thirty minutes per week to engage in religious activities. You stated you would like to use the gymnasium approximately four times per month or for bad weather days. After reaching out to my supervisor, we discussed that there is a potential that these spaces may not have to be licensed if they are only used for auxiliary spaces. I will reach back out to you with more information as we receive additional guidance. Technical assistance provided during today’s visit: •You must notify your consultant 30 days prior to changing the ownership status of your facility. •You must have a fire inspection prior to 10/17/2023. Once you receive an updated fire inspection, please send me a copy of the completed inspection. •You must have your water retested for lead again prior to 10/16/2023. For more information on how to conduct a retest, please visit this website: https://www.cleanwaterforuskids.org/en/carolina/ •You will need to review and revise (if applicable) your EPR plan annually. You will need to print the first page of the EPR plan to reflect the annual review date. You need to update your Ready-to-Go file. A Ready to Go File means a collection of information on children, staff and the facility, to utilize, if an evacuation occurs. The file shall include, a copy of the Emergency Preparedness and Response Plan, contact information for individuals to pick-up children, each child's Application for Child Care, medication authorizations and instructions, any action plans for children with special health care needs, a list of any known food allergies of children and staff, staff contact information, Incident Report forms, an area map, and emergency telephone numbers. •Make sure all employees complete a health questionnaire form annually. •Make sure all employees complete a professional development plan annually. •Make sure all employees receive six-clock hours of orientation within the first two weeks of employment. •Make sure all employees receive a copy of and review the Shaken Baby Syndrome Policy prior to caring for children aged birth through five-years-old. •On the staff and training worksheet, make sure you document when each employee receives a copy of the operational and personnel policies. •Make sure to document all on-going training hours on the on-going training log which can be located DCDEE’s website under provider documents. •Health and Safety training cannot be used to cover new staff orientation. New staff orientation must be provided by the facility and must be specific to the facility. Health and safety training is in addition to orientation not in place of. •Make sure to complete a playground inspection each month. •Make sure to complete an emergency drill every three months. •Make sure all outlets are covered using safety plugs at all times. •Make sure all medications have parent medication authorization forms on file. Make sure these forms are filled out completely including validity dates. •Make sure all medications are in their original packaging. •Make sure any emergency medication has an emergency action plan on file. •When following ratios for all children, you must follow the ratio for the youngest child using the minimum requirements, including your preschool afterschool children. •When a child has signed an opt out form, you are not required to provide any components unless the child does not bring any food. If a child does not have an opt out form but you allow them to pack lunch some days, you are required to supplement all components that are not provided by the family. •Exterior sandboxes must be covered. •If an employee leaves the facility and is gone longer than one year, all employee paperwork must be completed again. •If you will be taking your children outside of the fenced area to go to the gymnasium (if approved later), update your child files to include a permission to play outside the fenced area form. •Someone at the facility must be trained in Playground Safety by February 2024. This individual will conduct your playground inspections. This training must be completed in person. •Someone at the facility must be trained in Emergency Preparedness and Response by December 2023. This individual will conduct your emergency and fire drills. This training must be completed in person. •You are allowed to use Lysol at the end of the day when no children are present. Any cleaning supply that is an aerosol product must be kept in locked storage. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

10A NCAC 09 .0604 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 9/27/2023 Number Present: 41 Completed Date: 9/27/2023 Age: From 2 To 5 Total Minutes: 315 Time In: 09:00 AM Time Out: 02:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare facility to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant with Emily Pritchard, Director, and Tiffany Banks, Principal. Your program currently operates with a Notice of Compliance with restrictions of 1st Shift (daytime care) and children under 3 years old in rooms with direct exits only. The NC Secretary of State website was reviewed on 09/26/2023 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 92% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Seven classrooms are licensed for space for childcare at this facility. Spaces 100, 101, and 109 were not in use by preschool aged children in the licensed childcare facility. These classrooms were not fully monitored as they are not being used by the childcare facility at this time. Three classrooms, spaces 106, 107, and 108 were in use by preschool aged children during today’s visit and monitored per DCDEE procedures. Children were also observed in the licensed cafeteria having morning snacks. This space was monitored during today’s visit. During the walkthrough, I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. I observed two outlets that did not have safety plugs in space 106. Upon arrival, staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed positive interactions today. I observed children engaging in free play, routine activities, and group time. I observed developmentally appropriate materials and activities were available to the children in the classrooms. The last annual compliance visit was conducted on 10/24/2022. A sanitation inspection was completed 08/30/2023 with a superior classification. You provided me with a copy of this inspection during today’s visit. The last fire inspection was conducted 10/17/2022. Program records and required postings were monitored. A fire drill was conducted on 09/27/2023. A shelter in place drill was documented on 04/18/2023. An emergency drill was due in July 2023, and one was not observed. An outdoor inspection was documented on 09/14/2023. I did not observe a playground inspection for the month of August 2023. Staff files and children’s records were monitored per DCDEE procedures. I observed one employee file that did not have an annual staff professional development plan. I observed one employee file that did not have a current health questionnaire. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. I observed one employee file that did not complete six hours of orientation within the first two weeks of employment. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. Storage of hazardous items was monitored today. Hazardous items are stored in locked cabinets. Storage and administration of medication were monitored. Medication authorization was monitored. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. I observed one inhaler that did not include a medication authorization. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 807 A safe indoor and outdoor environment was not provided for the children. There were no safety concerns outdoors. I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. 10A NCAC 09 .0601(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. I observed two outlets that did not have safety plugs in space 106. 10A NCAC 09 .0604(c) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. .0803(2)(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. I observed one employee file that did not have a current health questionnaire. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. An emergency drill was due in July 2023, and one was not observed. .0604(u);.0302(d)(8) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. .0801(b) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. .0608(d)(1-4) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. I observed one inhaler that did not include a medication authorization. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 10/11/2023. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. During today’s visit, we discussed the possibility of using space 100 for music and movement. This is a licensed space and could be used as an auxiliary space. However, prior to using this space, be sure that you have covered all outlets with safety plugs and make sure that all cabinets do not contain items that should be in locked storage. We also discussed the removal of space 101 and/or 109 from your license. If you do not think you will ever use these spaces for the licensed childcare center and you wish to remove them from your license, reach out to me via email and we will begin the process. During today’s visit, we discussed possibly licensing the chapel and gymnasium as auxiliary spaces. You stated you would like to visit the chapel for approximately twenty to thirty minutes per week to engage in religious activities. You stated you would like to use the gymnasium approximately four times per month or for bad weather days. After reaching out to my supervisor, we discussed that there is a potential that these spaces may not have to be licensed if they are only used for auxiliary spaces. I will reach back out to you with more information as we receive additional guidance. Technical assistance provided during today’s visit: •You must notify your consultant 30 days prior to changing the ownership status of your facility. •You must have a fire inspection prior to 10/17/2023. Once you receive an updated fire inspection, please send me a copy of the completed inspection. •You must have your water retested for lead again prior to 10/16/2023. For more information on how to conduct a retest, please visit this website: https://www.cleanwaterforuskids.org/en/carolina/ •You will need to review and revise (if applicable) your EPR plan annually. You will need to print the first page of the EPR plan to reflect the annual review date. You need to update your Ready-to-Go file. A Ready to Go File means a collection of information on children, staff and the facility, to utilize, if an evacuation occurs. The file shall include, a copy of the Emergency Preparedness and Response Plan, contact information for individuals to pick-up children, each child's Application for Child Care, medication authorizations and instructions, any action plans for children with special health care needs, a list of any known food allergies of children and staff, staff contact information, Incident Report forms, an area map, and emergency telephone numbers. •Make sure all employees complete a health questionnaire form annually. •Make sure all employees complete a professional development plan annually. •Make sure all employees receive six-clock hours of orientation within the first two weeks of employment. •Make sure all employees receive a copy of and review the Shaken Baby Syndrome Policy prior to caring for children aged birth through five-years-old. •On the staff and training worksheet, make sure you document when each employee receives a copy of the operational and personnel policies. •Make sure to document all on-going training hours on the on-going training log which can be located DCDEE’s website under provider documents. •Health and Safety training cannot be used to cover new staff orientation. New staff orientation must be provided by the facility and must be specific to the facility. Health and safety training is in addition to orientation not in place of. •Make sure to complete a playground inspection each month. •Make sure to complete an emergency drill every three months. •Make sure all outlets are covered using safety plugs at all times. •Make sure all medications have parent medication authorization forms on file. Make sure these forms are filled out completely including validity dates. •Make sure all medications are in their original packaging. •Make sure any emergency medication has an emergency action plan on file. •When following ratios for all children, you must follow the ratio for the youngest child using the minimum requirements, including your preschool afterschool children. •When a child has signed an opt out form, you are not required to provide any components unless the child does not bring any food. If a child does not have an opt out form but you allow them to pack lunch some days, you are required to supplement all components that are not provided by the family. •Exterior sandboxes must be covered. •If an employee leaves the facility and is gone longer than one year, all employee paperwork must be completed again. •If you will be taking your children outside of the fenced area to go to the gymnasium (if approved later), update your child files to include a permission to play outside the fenced area form. •Someone at the facility must be trained in Playground Safety by February 2024. This individual will conduct your playground inspections. This training must be completed in person. •Someone at the facility must be trained in Emergency Preparedness and Response by December 2023. This individual will conduct your emergency and fire drills. This training must be completed in person. •You are allowed to use Lysol at the end of the day when no children are present. Any cleaning supply that is an aerosol product must be kept in locked storage. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times

NC GS 110-90 · Violation

Name of Operation: ST. JOHN'S LUTHERAN CHILD CARE Facility ID: 3455102 Consultant: WHITNEY PARKER Operation Type: Center Case Number: Visit Date: 9/27/2023 Number Present: 41 Completed Date: 9/27/2023 Age: From 2 To 5 Total Minutes: 315 Time In: 09:00 AM Time Out: 02:15 PM Time In: Time Out: List to Use: Center Type Of Visit: Annual Comp Full Announced/Unannounced: Unannounced An unannounced annual compliance visit was conducted at this childcare facility to monitor compliance with applicable childcare requirements. This visit was conducted by Whitney Parker, Childcare Consultant with Emily Pritchard, Director, and Tiffany Banks, Principal. Your program currently operates with a Notice of Compliance with restrictions of 1st Shift (daytime care) and children under 3 years old in rooms with direct exits only. The NC Secretary of State website was reviewed on 09/26/2023 and Saint John`s Evangelical Lutheran Church of the Unaltered Augsburg Confession, Incorporated was listed as current and active. The program’s compliance history was 92% prior to today’s visit. All programs are required to maintain at least 75% compliance. A walk-through of the facility was completed today. Indoor and outdoor areas were observed. Seven classrooms are licensed for space for childcare at this facility. Spaces 100, 101, and 109 were not in use by preschool aged children in the licensed childcare facility. These classrooms were not fully monitored as they are not being used by the childcare facility at this time. Three classrooms, spaces 106, 107, and 108 were in use by preschool aged children during today’s visit and monitored per DCDEE procedures. Children were also observed in the licensed cafeteria having morning snacks. This space was monitored during today’s visit. During the walkthrough, I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. I observed two outlets that did not have safety plugs in space 106. Upon arrival, staff/child ratio and space capacity were monitored as indicated on the attached worksheet. Supervision was adequate during the visit. I observed positive interactions today. I observed children engaging in free play, routine activities, and group time. I observed developmentally appropriate materials and activities were available to the children in the classrooms. The last annual compliance visit was conducted on 10/24/2022. A sanitation inspection was completed 08/30/2023 with a superior classification. You provided me with a copy of this inspection during today’s visit. The last fire inspection was conducted 10/17/2022. Program records and required postings were monitored. A fire drill was conducted on 09/27/2023. A shelter in place drill was documented on 04/18/2023. An emergency drill was due in July 2023, and one was not observed. An outdoor inspection was documented on 09/14/2023. I did not observe a playground inspection for the month of August 2023. Staff files and children’s records were monitored per DCDEE procedures. I observed one employee file that did not have an annual staff professional development plan. I observed one employee file that did not have a current health questionnaire. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. I observed one employee file that did not complete six hours of orientation within the first two weeks of employment. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. Storage of hazardous items was monitored today. Hazardous items are stored in locked cabinets. Storage and administration of medication were monitored. Medication authorization was monitored. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. I observed one inhaler that did not include a medication authorization. The program does not provide transportation. The following violations were cited during today’s visit: Violation Number Comment Rule 807 A safe indoor and outdoor environment was not provided for the children. There were no safety concerns outdoors. I observed a teacher lounge with an exposed coffee pot that was unlocked and accessible to children. 10A NCAC 09 .0601(a) 812 Electrical outlets and power strips, not in use, which were located in space used by children did not have safety outlets or were not covered with safety plugs unless located behind furniture or equipment that cannot be moved by a child. I observed two outlets that did not have safety plugs in space 106. 10A NCAC 09 .0604(c) 844 Prescribed medicine was not in original labeled container or accompanied by signed and dated written instructions from prescribing physician or health care professional. I observed one epi-pen that was stored in a plastic bag in space 107, not in the original packaging. I observed one inhaler stored in a plastic bag in space 106, not in the original packaging. .0803(2)(a) 1034 All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement. I observed one employee file that did not have a current health questionnaire. .0701(a) 1811 Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete. An emergency drill was due in July 2023, and one was not observed. .0604(u);.0302(d)(8) 1834 Application did not have a medical action plan attached for any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services. I observed one child that had an epi-pen for food allergies and did not have a medical action plan. .0801(b) 1874 The Prevention of Shaken Baby Syndrome and Abusive Head Trauma policy was not reviewed with new staff prior to providing care with children and/or a signed acknowledgement with all the required information was not maintained in the staff person's file. I observed one employee file that did not have a shaken baby syndrome policy receipt documented in their file prior to caring for children birth to five years of age. .0608(d)(1-4) 1882 Medication authorization, giving the caregiver standing authorization did not meet the specifications in rule. I observed one inhaler that did not include a medication authorization. .0803(6)(a-i); .0803(7)(a-g); .0803(8)(a-d) Child Care programs are expected to achieve and maintain compliance at all times and are required by NC GS 110-90(4) (d) to achieve and maintain an eighteen-month compliance history score of at least seventy-five percent. Any violation(s) documented may impact the compliance history score. You must correct the violations cited during today's visit immediately and send me documentation verifying compliance on or before 10/11/2023. The following information must be included in your signed and dated compliance letter: • the name of your center • facility ID number • date • title of the person who signs the letter • each violation number(s) • describes accurately and in detail how and when you corrected each violation You may email the letter to whitney.parker@dhhs.nc.gov or mail two copies of the letter to: Whitney Parker P.O. Box 1342 Lexington, NC 27293 If you state in your letter that corrections or changes have been made when they have not, it will be considered falsification of information and could lead to administrative action taken by the DCDEE. Repeated violations, continued non-compliance, or failure to submit the compliance letter prior to the date given in this visit summary can also lead to administrative action taken by the DCDEE. Additional monitoring visits may be conducted during the year to monitor compliance with applicable childcare requirements. During today’s visit, we discussed the possibility of using space 100 for music and movement. This is a licensed space and could be used as an auxiliary space. However, prior to using this space, be sure that you have covered all outlets with safety plugs and make sure that all cabinets do not contain items that should be in locked storage. We also discussed the removal of space 101 and/or 109 from your license. If you do not think you will ever use these spaces for the licensed childcare center and you wish to remove them from your license, reach out to me via email and we will begin the process. During today’s visit, we discussed possibly licensing the chapel and gymnasium as auxiliary spaces. You stated you would like to visit the chapel for approximately twenty to thirty minutes per week to engage in religious activities. You stated you would like to use the gymnasium approximately four times per month or for bad weather days. After reaching out to my supervisor, we discussed that there is a potential that these spaces may not have to be licensed if they are only used for auxiliary spaces. I will reach back out to you with more information as we receive additional guidance. Technical assistance provided during today’s visit: •You must notify your consultant 30 days prior to changing the ownership status of your facility. •You must have a fire inspection prior to 10/17/2023. Once you receive an updated fire inspection, please send me a copy of the completed inspection. •You must have your water retested for lead again prior to 10/16/2023. For more information on how to conduct a retest, please visit this website: https://www.cleanwaterforuskids.org/en/carolina/ •You will need to review and revise (if applicable) your EPR plan annually. You will need to print the first page of the EPR plan to reflect the annual review date. You need to update your Ready-to-Go file. A Ready to Go File means a collection of information on children, staff and the facility, to utilize, if an evacuation occurs. The file shall include, a copy of the Emergency Preparedness and Response Plan, contact information for individuals to pick-up children, each child's Application for Child Care, medication authorizations and instructions, any action plans for children with special health care needs, a list of any known food allergies of children and staff, staff contact information, Incident Report forms, an area map, and emergency telephone numbers. •Make sure all employees complete a health questionnaire form annually. •Make sure all employees complete a professional development plan annually. •Make sure all employees receive six-clock hours of orientation within the first two weeks of employment. •Make sure all employees receive a copy of and review the Shaken Baby Syndrome Policy prior to caring for children aged birth through five-years-old. •On the staff and training worksheet, make sure you document when each employee receives a copy of the operational and personnel policies. •Make sure to document all on-going training hours on the on-going training log which can be located DCDEE’s website under provider documents. •Health and Safety training cannot be used to cover new staff orientation. New staff orientation must be provided by the facility and must be specific to the facility. Health and safety training is in addition to orientation not in place of. •Make sure to complete a playground inspection each month. •Make sure to complete an emergency drill every three months. •Make sure all outlets are covered using safety plugs at all times. •Make sure all medications have parent medication authorization forms on file. Make sure these forms are filled out completely including validity dates. •Make sure all medications are in their original packaging. •Make sure any emergency medication has an emergency action plan on file. •When following ratios for all children, you must follow the ratio for the youngest child using the minimum requirements, including your preschool afterschool children. •When a child has signed an opt out form, you are not required to provide any components unless the child does not bring any food. If a child does not have an opt out form but you allow them to pack lunch some days, you are required to supplement all components that are not provided by the family. •Exterior sandboxes must be covered. •If an employee leaves the facility and is gone longer than one year, all employee paperwork must be completed again. •If you will be taking your children outside of the fenced area to go to the gymnasium (if approved later), update your child files to include a permission to play outside the fenced area form. •Someone at the facility must be trained in Playground Safety by February 2024. This individual will conduct your playground inspections. This training must be completed in person. •Someone at the facility must be trained in Emergency Preparedness and Response by December 2023. This individual will conduct your emergency and fire drills. This training must be completed in person. •You are allowed to use Lysol at the end of the day when no children are present. Any cleaning supply that is an aerosol product must be kept in locked storage. At the completion of the visit, this visit summary was reviewed with and provided to you. Thank you for your time and assistance during the visit. If you have any questions about the visit, please contact me or my supervisor using the information below. Whitney Parker, Child Care Consultant (336) 590-8765 whitney.parker@dhh.nc.gov Pamela Hauser, Supervisor pamela.hauser@dhhs.nc.gov For the latest information on childcare rules and regulations, please visit the Division of Child Development and Early Education's website at https://ncchildcare.ncdhhs.gov/ If the operator fails to correct any documented violations within the established time period, the Division of Child Development and Early Education may deny, suspend, terminate, or revoke any permit to operate (10A NCAC 09 .2000). All information in this report has been reviewed with me today.I understand that it is my responsibility to maintaincompliance with applicable NC Child Care Requirements at all times