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Evaluation Form (3) a Revised 3/2020 t ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HOME LICENSING EVALUATION RENEWAL Licensee: Dates) of Evaluation: 0 _`�'S n 2D 2 U Zmye of F ci ty: Date(s) of Follow-up: Cr-+ Addr91V /Co nty: a G d Purpose of Visit: o � ion 141i��U, Y 1 de4l L (9' 4 9' Telephone #: (99 ) W7510 3 ["Day Care 2rNighttime Care ❑ Family ['Grow ubs P Ca'� id y- --- - Licensed Capacity: Day I Night Age Range' Da ✓ Night / r -Days of Operation: - DayM. nigh - Hours of Operation: DayL� M Night 7. b rn License Number: Codes: O—Observed by DHR Licensing Representative Effective Dates of License: S—Certified by Licensee D—Discussed with Licensee From: To: X—Not Applicable-Not reviewed with Licensee 11 Deficiencies Noted: Yes ❑ No D Lincensing epre enta ive: ai t0 Sections to be completed at the discretion of the DH icensing Representative. U U U U REGULATIONS a CU REGULATIONS o cu Q Q — Q .Q — E E a E E Q- U Q U Y n Q 0 0 0 0 Z Z Z Z Licensing Procedures(II.,B.,pagA7., (4) Dangerous substances locked V 1. Provisions of license/permit(II (5) Aggressive animals not kept pages 12-13) JL a. Number of children in the care of the licensee do (6) Animals that pose a threat kept away from not exceed licensed capacity. children b. Ages range of children in care conforms to ages on (7)Fans in reach of children enclosed license. c. Current license/permit posted. O (8) Electrical outlets covered 0 The Home(II.C.,pages 15-24) Are any guns or firearms kept in the home or on the premises? 1. Indoor area(II.,C.,pages 15-19) Yes U/No ❑ a. Injury prevention(II.,C.,2.,a.,pages 15-16) (9) Guns/firearms unloaded (1) Home free of apparent hazardous conditions 0 (10) Guns/firearms in locked storage O (2) Home has electricity,water,gas,waste disposal (11) Ammunition stored separately from J� U guns/firearms in locked storage U (3) Home has working telephone V (12) Stairs have handrails in child's reach 1 ` U U U U N REGULATIONS ca YtEGULATYONS CU CL E E a U a 0 Q U o o o 0 Z Z Z Z (13) Smoking prohibited during hours of care (3) Number of playpens:2 O (14) Clear glass doors marked at child level 0 (4) No child shall sleep with an adult. (15) Tools and machinery inaccessible `-� (5) Each child younger than 12 months sleeps ,\ (.J alone in a crib or playpen. U (16) Hot tubs covered or drained during hours of care u (6) Crib slats no more than 2 3/8 inches apart (17) Working flashlight conveniently located (7) Crib mattress waterproof,good condition _(18) Consumption of alcohol prohibited during hours / (8) No infant put to sleep on sofa,soft mattress / of care JL or other soft surface. S (19) Non-prescription narcotic or illegal substances (9) Each child 12-18 months sleeps alone in a prohibited S crib,play pen or a low cot. (20)Bio contaminants shall be stored and disposed of (10) Two children over 18 months of the same / properly sex may share a double or larger bed or may sleep S alone b. Cleanliness and health(II.,C.,2.,b.,pages 16-17) (11) Beds,cribs,cots,or playpens clean and sanitary and free of hazards,maintained in good J� (1) Bathroom clean condition U (2) Foot stools for handwashing and toileting (12) Bedding adequate,appropriate to season (3) Potty chairs(if used)emptied,washed,disinfected / (13) Sheets and covers laundered weekly or after each use J more often when soiled. (4)Staff shall use Universal Precautions when (14) Number of beds: (� diapering or being exposed to bodily fluids (5) Rodentlinsect infestation prevented/eliminated (15) Number of cots: Cl (6) Garbage and trash stored in covered water-tight, (16) When not in use by family members,beds fly-proof containers and removed regularly covered with clean linens before used by children v in care. (7) Bedding,toys,utensils,toilets,sinks used by a (17) Waterbeds not used by a child sick person cleaned and disinfected before use by another person (8) Windows and doors used for ventilation screened 10 (18) Upper/top bunk beds not used by a child c. Space(II.,C.,2.,c.,page 17-18) (19) No child sleeps/naps on floors (1) Rooms well-lighted,ventilated,comfortably (20) Required indoor equipment provided. O cooled or heated as appropriate to the season 0 (See equipment checklist.for details) (2) Space for providing privacy to a child in care and (2 1) Recorded/printed material shall be ` members of the household as needed. previewed for appropriateness before shown to /� S 0 children (3) Clean,appropriate facilities for protection, (22) All material with sexually explicit, / storage,preparation of food. frightening,or violent content kept inaccessible 5 to children d. Equipment and furnishings (II.,C.,2.,d.,pages A 2. Outdoor area(II.,C.,pages 20-21) 18-19) U (1) Crib,bed,playpen or cot provided for each child �\ for rest/sleep during hours of care, (� (2) Number of cribs that meet the US Consumer Product Safety Act of 2008: 2 ` U U U U N REGULATIONS cco m REGULATIONS m CU E O a E o U Q U U Q c c o 0 Z Z Z Z a. Outdoor play area(page 20) (4) Person with current American Red Cross Lifeguard Training certificate in pool area at all times pool is in use (1) Children supervised at all times (5) Copy of Lifeguard Training Certificate on / file in home X (2) Outdoor play area free from apparent hazards (6) Wading structure less than 2 feet in depth, / has continuous adult supervision X (3) Fence at least 4 feet in height, free from sharp, (7)Wading structure/pool filled with clean f protruding edges (except where prohibited by federal water each day,emptied when not in use x law) _(S) The licensee is present during any swimming/wading activities (4) Required outdoor equipment provided (See 3. Transportation(pages 22-23) equipment checklist for details) (5) Outdoor play equipment not designed to b.e r-� Does the licensee provide portable,anchored V transportation for children in care? (6) Concrete or asphalt not used under equipment Yes ❑ No ❑ (7) Area free of stacked lumber,construction NOTE: The Department of Human Resources materials,firewood does not inspect activities away from the home. r The licensee shall assume full authority and (8) Stairs/steps have hand rails in child's reach responsibility for away from the home activities. l b. Injury prevention(page 20) a. Licensee responsible for children they , transport fix` (1) Home and grounds free of apparent hazards b. Licensee responsible for picking child up at including abandoned automobiles, unused appliance, the designated location and delivering the child / uncovered wells and cisterns, stacked lumber with V to the care of the designated person exposed nails,explosives 0 (2) Tools and machinery inaccessible to children C. Transportation Checklist used for transporting O by vehicle or walking(Sample checked) (3) All poison kept in locked area O d. Written consent to transport child X (4) Water hazards on or adjacent to home inaccessible e. No child left unsupervised in vehicle to children c. Swimming and wading (page 21) f. Driver has valid driver's license Is there a pool on the premises? g. Vehicle doors locked when moving Yes E] No �( (1) Swimming pool 2 feet or more in depth,enclosed h. All passengers and driver secured in a seat by fence or solid wall at least.4 feet in height,with no belt or child restraint which is properly anchored doors,windows,or other openings to the vehicle,installed and used according to x(2) Swimming pool has.locking gate. Gate and other manufacturer's instructions and maintained ingood condition. access areas locked when pool is not in use Do children in care use the pool? i. Each child secured in passenger restraint 1 Yes ❑ No system appropriate to age and size �( (3) Adult to child ratio in pool area: j. Each child younger than 1 year or weighing (a) One adult to each child younger than 2% less than 20 pounds secured in infant only orconvertible seat used in rear-facing position (b) One adult to three children 2'/: to 6 years i. Each child younger than 5 years or weighing less than 40 pounds secured in forward facing (c) One adult to five children 6 years and older seat 3 U v N U v a)REGULATIONS �_ M CU REGULATIONS �_ o m E E a n Q o Q E o Q 0. U U Q U Z Z U Z 0 k. Each child younger than 6 years secured in a booster (5) If parent/designated person cannot be reached,or if S seat illness/injury is severe,licensee shall obtain emergency treatment I. Each child 6 years and older secured in an individual (6) Parent urged to notify licensee if child is exposed to n seat belt. contagious disease U in. No child transported in front seat of vehicle with Does the licensee administer medication/medical passenger side air bag procedures? Yes ❑ No 4.Emergency Preparedness and Response Plans c. Medication/medical procedures administered only (pages 23-24) with written authorization from parent / See Checklist page 11 a. Emergency list posted by the phone /l (1) Blanket authorization forms are prohibited b. Substitutes/caregivers informed of responsibilities in (2) Prescription or over-the counter drugs in original / emergency container x c. Licensee and each caregiver has current infant-child /1 (3) Prescription drugs have pharmacy label or written CPR and first aid certificate. Copies on file in home 01 physician's written instructions Licensee and Members of the Household (4) Over the—counter drugs labeled with child's name / (II.,D.,pages 25-33) See checklist and directions X 1. Financial resources available (page 31) (5) Measuring device provided 2. At least one substitute available(page 31) (6) Medication for children or household members locked 3. Licensee does not work or attend school during (7) Medicines returned to child's parent when no longer hours of child care (page 33) needed x Care of the Children(II. E.,pages 34-40) (8) Time and date of medication documented in writing and kept in child's file in home 1. Supervision of the Children(page 34) (9) Copies of documentation available to parents on / request X a. Children supervised at all times. 4. Care of Infants(pages 36-37) b. Licensee responsible for care and supervision at all a. Each infant placed on back to sleep unless he/she has times written physician's instructions otherwise 2. Infants and children handled gently(page 34) /1 b. Each infant placed on stomach part of time he/she is U awake and observed 3. Health(pages 34-36) c. Positioning devices that restrict movement not used without written physician's instructions a. Each child observed for illness or injury upon arrival d. Soft materials,including pillows,quilts,comforters, ` sheepskins,bumper pads,stuffed toys prohibited in s b. Illness,injury,change in health reported to parent sleeping environment (1) Exposure to contagious disease reported to parent r e. Diapering area washable,cleaned and disinfected after T U each use. V (2) No child who is ill admitted to home f. Clean diapers and clothing provided for infants/toddlers. (3) Ill,injured child separated from group but (1 g. Wet,soiled diapers and clothing changed promptly continuously supervised U (4) Ill or injured child's parent notified immediately n h. Soiled diapers disposed of in plastic-lined containers and required to come for child or arrange for (vt O designated person to come for child 4 a) a) a) a) m a) REGULATIONS C REGULATIONS v Q Q - Q Q - E E a E a CL 0 0 U Q U Y Q o O o O Z Z Z Z i. Licensee/caregivers use Universal Precautions after b. Individual,disposable paper towels used for diapering or assisting with toileting,and contact with hand drying bodily fluids j. Individual disposable paper towels used for hand c. Feeding chairs provided for infants O drying k. Clean disposable gloves used for diapering each O d. Feeding chairs and tables cleaned and ,\ child disinfected before and after meals and snacks U 1. Each child's hands washed after diapering e. Each child's food served from an individual 0 dish m._No child left unattended while being diapered f. Each encouraged to experiment - with self-feeding n. Diapering area separate from food service, g. Utensils provided for each child preparation,and storage areas o. Infants handled gently,each infant's head supported, h h. Disposable utensils and cups used only under / rough or harsh handling prohibited. U close supervision �G 5. Child Abuse/Neglect Reporting(page.' i. Formula and food brought from child's home labeled and stored properly a. Known or suspected Child Abuse/Neglect reported n j. Milk and formula refrigerated immediately O as required. J b. Child abuse/neglect reports confidential k. Previously opened baby food jars not accepted c. Licensee,caregivers,and household members 1. Formula left in bottle after feeding discarded cooperate with DHR on any child abuse/neglect investigation,including providing information& in. Each infant held for bottle feeding. No bottles allowing access to children and records. propped. 6. Meals and Snacks(pages 38-39) n. Size of servings adequate to meet child's needs a. Meals and snacks provided as required. o. Food not forced or withheld Menu or foqd served o date of visit if observed:?3q p. Each child seated while eating O Jan clw i ) d10 Y"n 8. Food protection and preparation(page 39) <-- b. Formula or food for infants&other special diets a. Food in good condition O prepared as directed or provided by parent/guardian c. Special foods for children labeled with child's name b. No home-canned foods used and stored as directed U d.Formula,powder or concentrate,shall be prepared by c. Food protected from contamination O parent e. Fluid milk served. No powdered milk used for d. Food preparation surfaces and utensils cleaned O drinking before and after use f. Small,hard candies or nuts not served to children /1 e. Food that has been served to a child not served younger than 4 years again g. Foods that may cause choking prepared f. Tableware,utensils,food contact surfaces „ appropriately for the children cleaned after each.use U h. Foods served only under close supervision as g. Animals not allowed in food storage, / required (see page 36) preparation,or service areas during hours of care 5 7. Food Service (pages 38-39) h. Floors in food preparation and service areas D swept or vacuumed daily,mopped as needed a. Licensee,caregivers,each child washes hands with soap and warm running water as required 5 REGULATIONSU aREGULATIONS Q QQ E o Q -E o CL m U Q O U Q ..r U = O 0 0 z Z z Z 9. Personal Belongings (page 39) b. Most recent licensing evaluation posted a. Appropriate seasonal clothing for each child c. Most recent deficiency report posted provided by parent b. Sufficient clean,dry diapers and clothing provided O d. Public notice form posted r\ for each infant/toddler U c. Space for each child for storing personal belongings e. Corrective/adverse action notices posted 10. Disciplinary Practices(pages 39-40) f.Emergency Preparedness an Response Plan posted U a. Discipline appropriate to age and developmental ----- — - g. Information about children kept confidential level of the children b. No corporal/physical punishment h. Written rules and policies provided to parents when child is enrolled c. No verbal abuse i. Parents and DHR notified of changes in written / rules and policies S d. Discipline not associated with food,naps,or n j. Licensee's social security number available to bathroom procedures u parents on request e. No physical restraint as punishment 2. Reports to the Department(pages 42-43) f. No punishment administered by another child a. Enrollment reports submitted as requested . g. Rough or harsh handling prohibited b. Child abuse/neglect reported as required by law 11. Outdoor Play (page 40) c. The following reported to DHR within 24 hours,written report within 5 days: Children spend time outdoors each day,when weather n (1) Any illness/injury requiring professional n permits V medical treatment J 12. Sign in/Sign out Procedures (page 40) (2) Any illness/injury requiring emergency medical treatment a. Each child signed in at arrival V (3) Any death occurring in the home b. Each child signed out at departure V (4) Changes in caregivers or substitutes. 13. Release of Children(page 40) (5) Change in licensee's name. a. No child released to anyone without written (6) Change in name or number of street address (' authorization from parent u b. Photo ID required for unfamiliar persons picking up (7) Change in telephone number r a child J 14. Visits by parents/guardians(page 40) (8) Serious accident or illness of the licensee or members of the household - a. Parents have right to visit at any time (9) Serious damage to the home or grounds b. Parents informed of right to visit (10) Changes in members of the household. Administration (II.,F.,pages 41-45) (11) Any arrest of licensee,household member, caregiver,substitute 1. General administrative responsibilities (pages (12) Final disposition of any child 41-42) abuse/neglect investigation involving licensee, household member,caregiver,substitute a. Current license/permit posted (13)Any disastrous events U 6 a) a) a) (D a) a) REGULATIONS CU REGULATIONS o C E E o- U 0 Q O U Q �. U CL Z Z Z� Z d. Physical/structural changes to home or grounds d. Individual soap,towel,and washcloth provided reported in advance for each child e. Any change in location reported in advance (New 3.Sleeping requirements (page 46) license is required) 3. Records to be kept by the licensee(pages 43-45) a. Each child younger than 18 months sleeps alone in crib a. Record for licensee/household members(see checklist) b. Number of cribs that meet the US OConsumer Product Safety Act of 2008: b. Records for caregiver/substitute(see checklist) U C. Infants placed on back to sleep I O:3 4 r ch V - mon -c.Records on caregivers/substitutes kept at least two d. Each child 18 ths and older sleeps in a bed - years after person leaves d. Certificate of rabies vaccination e. Number of beds: e. Children's records complete(see checklist) 4. Each child's toilet articles labeled with name, kept separate,kept in sanitary condition f. Children's records kept at least two years after child / 5. Breakfast served to each child who goes p leaves S directly to school unless provided by school or J� parent g. Children's records and information about children 6. Evening meal provided for each child and their families kept confidential continuing from day time care �s h. Confidential information accessible only to ` H. Group Day Care Homes(pages 47- authorized persons !J- 49) This section to be completed for i. Transportation checklists kept for current year plus homes providing care for 7 to 12 two additional years children. j. Sign in/sign out sheets kept for current year plus two 1. At least two adults present and supervising the additional years children when seven of more children are present G. Nighttime Care(page 46) 2. If a substitute is used,the licensee or assistant caregiver is resent This section to be completed for homes3.providing care after 7p.m. Complete record for assistant caregiver 1. Number and age range of children does not exceed n 4. Outdoor play area fenced V number and age range on license/permit J. 2. Bathing (page 46) 5. Required equipment provided(See checklist for details) 0 a. Clean water provided for each child I. Group Nighttime Homes(page 50) This section to be completed for homes b. Each child bathed separately providing care for 7 to 12 children after 7 p.m. c. Each child supervised while bathing 1. At least two adults present and supervising the children when seven of more are present 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. / (0 Signature licensee or designated—staff / Date 7 Emer2ency 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) ' Do on 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 O Severe Thunderstorms Tornadoes Flash flooding —Major snowfall Blizzards Ice storms Earthquakes Lockdown or evacuation due to threats of violence Location and use of fire extinguishers Evacuations due to; V #Documentation of the following quarterly drills; Hazardous materials O Fire Spills Tornado Gas leaks O 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 Details, vailability J." The disaster plan shall include details for: The Emergency Preparedness and Response Plans should be: Shelter in place or evacuation D Available to all staff and employees Assisting infants and children with special needs and/or health Posted in a Conspicuous place ,l conditions V Reunification with parents O Submitted to the Department Supplies needed for shelter in place procedures Copies provided to all parents/guardians Transportation disaster procedures C� Staff training/reassignment as appropriate #Plan updated yearly Contact with local emergency management officials g Equipment Checklist Codes: Use the following code when completing the columns for each category. ( O ) indicates compliance observed (4) indicates not in compliance (X )indicates not applicable The licensee shall provide a variety of toys,games,and other play equipment appropriate to the ages of children specified on the license/permit and to the interests of the children. For Family Day Care Homes,the licensee shall provide at least two(2)items from each category for each age group for which the home is licensed or permitted. For Group Day Care Homes the licensee shall provide at least four(4)items from each category for each age group. 2. Equipment for Children 2t/z markers,paper,chalk,blunt-end 1. Equipment for Children scissors,paste,glue,playdough, Up to 2t/z Years Years up to 6 Years paints(tempera or water color), for • • • • long handled brushes,finger paints V Toys For A variety of age-appropriate booksPlay O Sand or digging area with items for accessible to the children Small wheel toys digging,filling,sifting,and pourin A device that plays a variety of age- Push music (� Push and pull toys Climbing structure with soft Rhythm instruments --------------------- Boxes of assorted sizes surface undemeath Swings with safety seat,infant swing Wheel toys 0f. Nature and Science U Buckets for water play,items for Materials Sand or digging area toys for , , Collections o rocs, eaves,seeds, h digging, ourin ,siftin _pouring,measuring floating Clli fk l lJ Large Balls '. Toys forQuiet Play etc. ' Quiet toys Puzzles Aquarium with fish (must be J Beads or spools and string for covered Simple puzzles O X stringing Magnifying glass 11Nesting and stacking toys Peg boards and pegs Magnets 1 Soft dolls and clothes Matching games such as lotto, Measuring equipment Cars,trucks,trains picture dominoes and other simple 3. Equipment for Children 6 Large beads or spools to string games Picture books Creative construction sets 0 Years and Older Blocks a. Storage c. Art materials Small cars,trucks,boats,trains Children shall have a separate area Paper for storing their personal items and Non-toxic crayonsMake-believerojects blankets with clothes, , Non-toxic water color markers Dolls,Q UBooks storage area Non-toxic play dough Doll stroller Non-toxic art materials:a variety of kinds of paper, scissors, glue, ' ' toys Doll bed or cradle crayons, markers, chalk, paints, r' Crib mobiles(for infants younger Dress-up clothes clay,playdough v than 5 months) Home living area-kitchen Books and magazines appropriate J� Washable teething rings O appliances may be purchased or (� to the ages of the children V Rattle toys made from cardboard boxes A device that plays a variety of age- 0 Squeeze toys Play dishes,plastic baby bottles, apro riate music and stories pots and pans,mea.suring spoons c. • Soft cuddly toys Puppets Dress-up clothes ramatic Play Props Busy boxes 0 Sheet or bedspread for making a v Dolls and dolls clothes e. Make-believe Play tent Costumes and masks Dolls,and clothes and blankets d Cardboard boxes in assorted sizes • • • Dress-up clothes Mirror Interlocking manipulative play sets r quiet time Homeliving area-pretend kitchen Toy telephone Jigsaw puzzles appliances pans, made from boxes • Board games and playing cards Toys,dishess,,pans,spoons,plastic Dish pan containers with lidsEquipment Toy telephone Sponges 0 Active/Outdoor Play Puppets 0 Bubble mixture Balls Strainers Funnels Bats 0 Egg beaters Tether ball Small boats and other floating toys Croquet set e. Art, Books, Music Badminton set Non-toxic art materials-large Horseshoes �( encils and crayons,water color o Wheel toys 11