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Evaluation Form (4) Revised 3/2020 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HOME LICENSING EVALUATION ANNUAL Licensee: p rri6 M04*0 Dates of Evaluation: A 03 Name of Facility:-C OC re_r Date(s) of Follow-up: Address: `I Lo ZJ Mp.tV;, L0.ne, Purpose of Visit: �G1 p ,4L 5 b5 3 22 Tele hone#: 2S1 ql-Mo 7 Day.Care Nighttime Care Famil [:1 Group El Subsid Licensed Capacity: Da Ni htN Age Ran e: Day' 6 J2 Ni ht P A Days of Operation: Da -r Ni ht NKA Hours of O eration: I Da ]-00rl Night Nightm A License Number: P 4DJ OODOS Codes: Effective Dates of License: O—Observed by DHR Licensing Representative From: �{ Z S—Certified by Licensee I'd To• D—Discussed with.Licensee County: X—Not Applicable-Not reviewed with Licensee Deficiencies Noted: Yes ❑ No QHR Licensing Re a entativ Sections to be completed at the discretion of the DHR Licensing Representative. (U a) a) a) a) a) REGULATIONS REGULATIONS � U - - U E E Q. O E 0- O a- O O- O U Q O U Q U o 0 o O .Z Z Z Z Licensing Procedures(II.,B.,pages 11- (10) Guns/firearms in locked storage 14 1. Provisions of license/permit(II.,B.,7., (11) Ammunition stored separately from pages 12-13) guns/firearms in locked storage a. Number of children in the care of the (12) Stairs have handrails in child's reach licensee does not exceed licensed capacity b. Ages range of children in care conforms (13) Smoking prohibited during hours of care to ages on license c..Current license/permit posted (14) Clear glass doors marked at child level The Home(II.C.,pages 15-24) (15) Tools and machinery inaccessible CD 1. Indoor area(II.,C.,pages 15-19) (16) Hot tubs covered or drained during hours of v care J� a. Injury prevention(II.,C.,2.,a.,pages (17) Working flashlight conveniently located 15-16) 0 (1) Home free of apparent hazardous (18) Consumption of alcohol prohibited during C conditions O hours of care J (2) Home has electricity,water,gas,waste (19) Non-prescription narcotic or illegal substances c disposal o prohibited J (3) Home has working telephone O (20)Bio contaminants shall be stored and disposed e of properly J (4) Dangerous substances locked Q b. Cleanliness and health(II.,C.,2.,b.,pages 16-17) (5) Aggressive animals not kept rj (1) Bathroom clean (6) Animals that pose a threat kept away C (2) Foot stools for handwashing-and toileting from children J (7)Fans-in reach of children enclosed (3) Potty chairs(if used)emptied,washed, disinfected after each use (8) Electrical outlets covered O (4) Staff shall use Universal Precautions when diapering or being exposed to bodily fluids Are any guns or firearms kept in the ome or (5) Rodent/insect infestation prevented/eliminated C on the remises? Yes ❑ No J (9) Guns/firearms unloaded (6) Garbage and trash stored in covered water-tight, I� fly-proof containers and removed regularly 1 REGULATIONS U U REGULATIONS T T C)- a � Q 0 o E o C- O U Q O U Q C) o 0 U o 0 z z z z (7) Bedding,toys,utensils,toilets, sinks (17) Waterbeds not used by a child used by a sick person cleaned and disinfected before use by another person (8) Windows and doors used for S (18) Upper/top bunk beds not used by a child y ventilation screened �i c. Space II.,C.,2.,c.,pages 17-18 (19) No child sleeps/naps on floors (1) Rooms well-lighted,ventilated, 2. Outdoor area (II.,C.,pages 20-21) comfortably cooled or heated as appropriate to the season (2)Space for providing privacy to a child in ® a. Outdoor play area(page 20) care and members of the household as needed (3)Clean, appropriate facilities for (1) Children supervised at all times protection,storage,preparation of food d. Equipment and furnishings(II.,C., (2) Outdoor play area free from apparent hazards 2.,d.,pages 18-19) 707 (1)Cribs,bed,playpen or cot provided for (3) Fence at least 4 feet in height,free from sharp, each child for rest/sleep during hours of care protruding edges(except where prohibited by federal 1 D law (2) Number of cribs that meet the US (4) Outdoor play equipment not designed to be O Consumer Product SafetyAct of 2008: portable,anchored 3 Number of playpens: PF (5) Concrete or asphalt not used under equipment (4) No child shall sleep with an adult (6) Area free of stacked lumber, construction materials, firewood (5) Each child younger than 12 months (7) Stairs/steps have hand rails in child's reach sleeps alone in a crib or lay en (6) Crib slats no more than 2 3/8 inches b. Injury prevention(page 20) apart (7) Crib mattress waterproof,good (1) Home and grounds free of apparent hazards condition including abandoned automobiles,unused appliance, uncovered wells and cisterns, stacked lumber with exposed nails,explosives (8) No infant put to sleep on sofa,soft (2) Tools and machinery inaccessible to children O mattress or other soft surface (9) Each child 12-18 months sleeps alone y (3) All poison kept in locked area in a crib,play pen or a low cot (10) Two children over 18 months of the (4) Water hazards on or adjacent to home same sex may share a double or larger bed inaccessible to children X or may sleep alone (11) Beds,cribs,cots, or playpens clean c. Swimming and wading (page 21) and sanitary and free of hazards, maintained in good condition (12) Bedding adequate, appropriate to Is there a pool on the premises? season S1 I Yes ❑ No E 1__ M (13) Sheets and covers laundered weekly (1) Swimming pool 2 feet or more in depth, or more often when soiled S enclosed by fence or solid wall at least 4 feet in (14) Number of beds: height,with no doors,windows,or other openings 15 Number of cots: (2) Swimming pool has locking gate/Gate and (16) When not in use by family members, other access areas locked when pool is not in use beds covered with clean linens before used by children in care 2 REGULATIONS CU m v REGULATIONS M 0 � 0 o o U 0 Q U v Q 0 0 0 O Z Z Z Z Do children in care use`tl)e pool? j. Each child younger than 1 year or weighing less Yes ❑ No j`�tj' than 20 pounds secured in infant only or convertible seat used in rear-facingposition (3) Adult to child ratio in pool area: k. Each child younger than 5 years or weighing less than 40 pounds secured in forward facing seat (a) One adult to each child younger than �/ L Each child younger than 6 years secured in a J( 2'/z ✓� booster seat (b) One adult to three children 2'/z to 6 in. No child transported in front seat of vehicle with �( ears passenger-side air bag x` (c) One adult to five children 6 years and older (4) Person with current American Red 4. Emergency Preparedness and Response Plans Cross Lifeguard Training certificate in pool (pages 23-24) area at all times pool is in use See Checklist page 9 (5) Copy of Lifeguard Training Certificate Licensee and each caregiver has current infant-child on file in home X CPR and first aid certificate/copies on file in home (6) Wading structure less than 2 feet in Licensee and Members of the Household(II., depth,has continuous adult supervision G pages 25-33) See checklist (7)Wading structure/pool filled with clean Licensee does not work or attend school during water each day,emptied when not in use hours of child care (page 33) (8) The licensee is present during any Care of the Children(II.E., pages 34-40) swimming/wading swimming/wading activities 3. Transportation a es 22-23 1. Supervision of the Children(page 34 Does the licensee provide transportation a. Children supervised at all times for children in care? Yes ❑ No NOTE: The Department of Human b. Licensee responsible for care and supervision at Resources does not inspect activities away all times from the home.The licensee shall assume full authority and responsibility for away from the home activities. a. Licensee responsible for children they 2. Infants and children handled gently(page 7ii trans ort b. Licensee responsible for picking child up 3. Health(pages 34-36) at the designated location and delivering the child to the care of the designated person c. Transportation Checklist used for a. Illness, injury, change in health reported to parent transporting by vehicle or walking(Sample S' checked) d. Written consent to transport child (1)No ill child admitted to home e. No child left unsupervised in vehicle (2)111, injured child separated from group but continuously supervised f. Driver has valid driver's license (3) Ill or injured child's parent notified immediately g. Vehicle doors locked when moving and required to come for child or arrange for designated person to come for child h. All passengers and driver secured in a (4) If parent/designated person cannot be reached,or seat belt or child restraint which is properly if illness/injury is severe, licensee shall obtain anchored to the vehicle, installed and used emergency treatment according to manufacturer's instructions and maintained in good condition i. Each child secured in passenger restraint Does the licensee administer medication/medical system appropriate to age and size procedures? Yes ❑ No C.Medication/medRaT procedures administered only Q with written authorization from parent J� 3 REGULATIONS c�a v REGULATIONS 0 v 0 o a 1= o 0- UC) Q U 0 Q 0 0 0 0 Z Z Z Z (1)Blanket authorization forms are Menu or food served on date of visit if observed: prohibited x aL if* ScrOL 121ed S, d r j �( w v-4 c. (2)Prescription or over the counter drugs in d. Small,hard candies or nuts not served to children c original container younger than 4 years J (3) Prescription drugs have pharmacy label41� e. Foods that may cause choking prepared C or written physician's written instructions appropriately for the children J (4) Over-the—counter drugs labeled with f. Foods served only under close supervision as c child's name and directions required (see page 36) J 4. Care of Infants(pages 36-37 7. Food Service (pages 38-39 a. Each infant placed on back to sleep unless a. Licensee,caregivers,each child washes hands he/she has written physician's instructions �/ with soap and warm running water as required 0 otherwise x b. Soft materials, including pillows,quilts, b. Individual, disposable paper towels used for hand comforters,sheepskins,bumper pads,stuffed �( drying ?� toys prohibited in sleeping environment /\ V c.Diapering area washable,cleaned and c. Formula and food brought from child's home disinfected after each use labeled and stored properly d. Soiled diapers disposed of in plastic-lined �/ d. Each infant held for bottle feeding/No bottles containers /1 propped X e. Licensee/Caregivers use Universal e. Each child seated while eating Precautions when diapering, or assisting with toiletin f.Individual disposable paper towels used 9. Personal Belongings (page 39) for hand drying g. Clean disposable gloves used for �( a. Appropriate seasonal clothing for each child diapering each child provided by parent h.Each child's hands washed after diapering b. Sufficient clean,dry diapers and clothing O provided for each infant/toddler i.Diapering area separate from food service, Y c. Space for each child for storing personal preparation, and storage areas belongings �J j. Infants handled gently, each infant's head 10. Sign in/Sign out Procedures (page 40) supported,rough or harsh handling prohibited 5. Child Abuse/Neglect Reporting(page a. Each child signed in at arrival 37 a. Known or suspected Child Abuse/Neglect b. Each child signed out at departure reported as required b.Child abuse/neglect reports confidential 11. Release of Children(page 40 c.Licensee,caregivers, and household a. No child released to anyone without written members cooperate with DHR on any child authorization from parent abuse/neglect investigation, including providing information&allowing access to children and records 6. Meals and Snacks(pages 38-39) b. Photo ID required for unfamiliar persons picking up a child a. Meals and snacks provided as required Administration II.,F.,pages 41-45 b. Formula or food for infants&other 1. General administrative responsibilities (pages special diets prepared as directed or provided S 41-42) by parent/guardian c. Formula,powder or concentrate,shall be y a. Current license/permit posted prepared by parent 4 REGULATIONS m T c REGULATIONS M csa CU E0 E 0- E E 0- 0 Q- 0 C- 0 0 Q 0 U Q U 0 0 U 0 0 z Z Z Z b. Most recent licensing evaluation posted c. Records on caregivers/substitutes kept at least two ears after person leaves c. Corrective/adverse action notices osted d. Certificate of rabies vaccination d. Most recent deficiency report posted e. Children's records complete(see checklist) e. Public notice form posted f. Transportation checklists kept for current year © lus two additional years f. Emergency Preparedness and Response cc�� g. Sign in/sign out sheets kept for current year plus Plan osted V two additional years g.Licensee's social security number G. Nighttime Care(page 46) available to parents on request S This section to be completed for homes providing care after 7 p.m. 2. Reports to the Department(pages 42- 1. Number and age range of children does not 43) exceed number and age range on license/permit b. Child abuse/neglect reported as required 2. Bathing (page 46) by law c. The following reported to DHR within 24 a. Clean water provided for each child hours,written report within 5 days: (1) Any illness/injury requiring C b. Each child bathed separately professional medical treatment J (2) Any illness/injury requiring emergency C c. Each child supervised while bathing medical treatment J (3) Any death occurring in the home d. Individual soap,towel, and washcloth provided for each child (4) Changes in caregivers or substitutes (5) Change in licensee's name 3. Sleeping requirements (page 46 (6) Change in name or number of street C a. Each child younger than 18 months sleeps alone address J in crib (7) Change in telephone number b. Number of cribs that meet the US Consumer Product Safety Act of 2008: N (8) Serious accident or illness of the C c. Infants placed on back to sleep licensee or members of the household J 9) Serious damage to the home or grounds d.Each child 18 months and older sleeps in a bed Al— (10) Changes in members of the household C e. Number of beds: N 1 P (11) Any arrest of licensee,household 4. Each child's toilet articles labeled with name, member,caregiver,substitute kept separate,kept in sanitary condition (12) Final disposition of any child 5. Breakfast served to each child who goes directly abuse/neglect investigation involving S to school unless provided by school or parent licensee,household member,caregiver, substitute (13)Any disastrous event 6. Evening meal provided for each child continuing from day time care d. Physical/structural changes to home or H. Group Day Care Homes(pages 47-49) grounds reported in advance S This section to be completed for homes providing care for 7 to 12 children. e. Any change in location reported in S` 1. At least two adults present and supervising the advance (New license is required) children when seven of more children are present 3. Records to be kept by the licensee 2. If a substitute is used,the licensee or assistant (pages 43-45 caregiver is present a. Record for licensee/household members D 3. Complete record for assistant caregiver see checklist) b. Records for caregiver/substitute(see Q 4. Outdoor play area fenced checklist) 5 REGULATIONS M 0 m REGULATIONS m 0 a E 0 a U c� Q U Q 0 0 0 0 Z Z Z Z I. Group Nighttime Homes(page 50) This section to be completed for horses providing care for 7 to 12 children after 7 X .m. 1. At least two adults present and supervising the children when seven of more are present X X 2. Number and age range of children does not exceed number and age range on license/permit The deficiencies noted have been discussed with me. Failure to correct the deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of the Minimum Standards. A facility licensed by the Department must meet Minimum Standards at all times. It is the responsibility of the licensee to operate in compliance with the Minimum Standards. Signature of license or designated staff Date 6 Emergency Preparedness and Response Plans Checklist (O)indicates compliance observed by DHR Licensing Representative (d)indicates not in compliance (S ) indicates certified by staff in charge(use only for#plan updated yearly,written documentation must be on file) Documentation The plan shall include procedures that will be used to prepare for The plan should also be inclusive of and respond to the following types of emergency/disaster situations: Weather emergencies/natural disasters; Current emergency plans and procedures Severe Thunderstorms Tornadoes Flash flooding Major snowfall v Blizzards Ice storms v Earthquakes Lockdown or evacuation due to threats of violence toe Location and use of fire extinguishers Evacuations due to; #Documentation of the following quarterly drills; Vol Hazardous materials Fire Spills Tornado Gas leaks ✓ Lockdown Bomb threats Relocation Fire Infectious disease emergencies ✓ Telephones for on-site and off-site use `/ Loss of power,water,or heat ✓ Location of the first aid and emergency supply kits ✓ Other threatening situations V Details The disaster plan shall include details for: The Emergency Preparedness and Response Plans should be: Shelter in place or evacuation ✓ Available to all staff and employees Assisting infants and children with special needs and/or health Posted in a Conspicuous place conditions Reunification with parents ✓ Submitted to the Department.' _ / Supplies needed for shelter in place procedures ,/ Copies provided to all parents/guardians v/ Transportation disaster procedures Staff training/reassignment as appropriate ✓ #Plan updated yearly Contact with local emergency management officials 7