Mt. Pisgah Lutheran Preschool

All equipment and furnishings were not in good repair.

“The large playground has several areas of chipping and peeling paint.”

Rule All equipment and furnishings were not in good repair.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement.

“One staff, per the staff and training worksheet had an annual health questionnaire on file dated 6/11/2025.”

Rule All staff, including the director, did not have an annual health questionnaire on file following the initial medical statement.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually.

“One staff, per the staff and training worksheet had an emergency information form on file dated 6/11/2025.”

Rule Child care providers, including the director, uncompensated providers, substitute providers, and volunteers did not have the required Emergency Information Form on file on or before the first day of work, which included all the required information and/or the information on the form was not updated as changes occur and at least annually.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

Each employee’s personnel file did not contain an annual staff evaluation and a staff development plan.

“One staff, per the staff and training worksheet, had an annual staff evaluation and staff development plan on file dated 6/11/2025.”

Rule Each employee's personnel file did not contain an annual staff evaluation and a staff development plan.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas.

“One (1) newly hired staff, per the staff and training worksheet, did not complete six hours of training in the required topic areas within the first two weeks of employment.”

Rule Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics.

“One staff, per the staff and training worksheet has not completed training in the health and safety topics within five years of completed the previous health and safety training topics.”

Rule Health and safety training topics were not included as part of on-going training within five years of completing the previous health and safety training topics.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 13, 2026. Correction verified: by a letter from the provider.

Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection.

“Operator did not submit the original approved report to DCDEE within one week of the inspection visit on a form provided by the Division. The most recent fire inspection on file was dated 6/11/2025.”

Rule Operator has not scheduled and obtained a fire inspection within 12 months of the previous inspection.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 9, 2026. Correction verified: by a letter from the provider.

A safe indoor and outdoor environment was not provided for the children.

“A staff member failed to ensure a safe environment for children when a four-year-old child exited the playground and entered a busy road causing cars to stop before the staff member retrieved the child.”

Rule A safe indoor and outdoor environment was not provided for the children.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 8, 2026. Correction verified: at a follow-up visit by DCDEE.

Children between 12 and 24 months of age were grouped with children 3 years of age or older.

“On March 25, 2026, a four-year-old child was grouped with one and two-year-old children on the playground for approximately thirty minutes.”

Rule Children between 12 and 24 months of age were grouped with children 3 years of age or older.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 8, 2026. Correction verified: at a follow-up visit by DCDEE.

Children were not adequately supervised at all times.

“On March 25, 2026, a staff member was seated on a crate and was not providing adequate supervision for one- and two-year-old children. Another staff member was not immediately aware when a four-year-old child exited the fenced playground and ran towards a highway.”

Rule Children were not adequately supervised at all times.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 8, 2026. Correction verified: at a follow-up visit by DCDEE.

There was a substantiation of child maltreatment.

“The Division confirmed sufficient information to determine child maltreatment based on supervision needs of children.”

Rule There was a substantiation of child maltreatment.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 8, 2026. Correction verified: at a follow-up visit by DCDEE.

A current activity plan was not posted for each group of children for reference.

“An activity plan with the end date of 6/30/25 was posted in the classroom of two year-olds.”

Rule A current activity plan was not posted for each group of children for reference.. Corrected during the inspection.

Child care providers and uncompensated providers who are not substitute providers or volunteers, including the director did not have a medical report on file prior to employment that was signed by a health care professional and/ or the medical report was older than 12 months.

“One staff, per the staff and training worksheet, hired 8/12/24, has a medical report on file dated 8/13/24.”

Rule 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.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 10, 2025. Correction verified: by a letter from the provider.

All staff did not successfully complete certification in CPR training appropriate to the age of the children in care.

“Verification of staff completion of the CPR course from an approved training organization was not in the staff file. Staff M.H. does not have current CPR training.”

Rule All staff did not successfully complete certification in CPR training appropriate to the age of the children in care.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Mar 5, 2025. Correction verified: by a letter from the provider.

All staff did not successfully complete certification in First Aid appropriate to the age of children in care.

“Verification of staff completion of First Aid training from an approved training organization was not in the staff file. Staff M.H. does not have current First Aid training.”

Rule All staff did not successfully complete certification in First Aid appropriate to the age of children in care.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Mar 5, 2025. Correction verified: by a letter from the provider.

Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas.

“One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first two weeks of employment, six clock hours of orientation training in required topic areas.”

Rule Each new employee did not complete, within the first two weeks of employment, six clock hours of training in required topic areas.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 19, 2024. Correction verified: by a letter from the provider.

Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization.

“One (1) over the counter medication on-site, in classroom #6, Aquaphor healing ointment, expired 3/2024.”

Rule Leftover medicines were not returned to the parent after the course of treatment was completed, after authorization was withdrawn or after authorization had expired and/or medication was not discarded within 72 hours of completion of treatment or withdrawal of authorization.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 19, 2024. Correction verified: by a letter from the provider.

New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks.

“One (1) staff, hired 5/6/24, per the staff and training worksheet, did not complete, within the first six weeks of employment, sixteen clock hours of orientation training in required topic areas.”

Rule New staff, who had contact with children, did not receive at least 16 hrs. orientation within first 6 weeks.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Jul 19, 2024. Correction verified: by a letter from the provider.

On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months.

“One staff, per the staff and training worksheet, has a TB test on file which is older than 12 months of first day of work.”

Rule On or before the first day of work, all staff, including the director and individuals who volunteer more than once per week did not provide results indicating that they were free of active TB and/or TB test or screening was older than 12 months.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Mar 5, 2024. Correction verified: by a letter from the provider.

Rule violated (DCDEE’s description below)

“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. ne staff, per the staff and training worksheet has a medical statement on file older than 12 months from the date of employment.”

Rule Rule violated (DCDEE’s description below). Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Mar 5, 2024. Correction verified: by a letter from the provider.

Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete.

“A lockdown or shelter-in-place drill was practiced 5/22/23; the next lockdown or shelter-in-place drill was practiced 9/13/23.”

Rule Shelter-in-place or lockdown drills were not practiced every three months and/or drill record was incomplete.. Correction date, as North Carolina Department of Health and Human Services, Division of Child Development and Early Education (DCDEE) recorded it: Mar 5, 2024. Correction verified: by a letter from the provider.