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Evaluation Form l 1/19 ALA.,AMA DEPARTMENT OF HUMAN...,,SOURCES CHILD CARE HOME LICENSING EVALUATION Short Form Licensee: Dates of Evaluation: ��I Name of Facility: Date(s) of Follow-up: Address:-- Purpose of Visit: Telephone#: EVFDay Care Pr Nighttime Care ❑ Famil Group Subsidy htAe Range: DaA Night--4 Capacity: Da Days of Operation: Da Night A( Hours of Operation: Night License Number: 00.2- Codes: Effective-Dat so License: O-Observed by DHR Licensing Representative From: 7 To• S-Certified by Licensee D-Discussed with Licensee County: X-Not Applicable-Not reviewed with Licensee Deficiencies Noted: es ❑ No DH Licensing epr entative: Sections to be completed at the discretion of-the DHR Licensing Representative. U V a) REGULATIONS REGULATIONS c� m U Q E E cL a E o Q o 0 Q U 0 Q U 0 o o Z o Z Z Z Licensing Procedures(II.,B.,pages 11- (9) Guns/firearms unloaded 15 1. Provisions of license/permit(II.,B.,7., (10) Guns/firearms in locked storage �( pages 12-15 a. Number of children in the care of the (11) Ammunition stored separately from licensee does not exceed licensed capacity guns/firearms in locked storage b. Ages range of children in care conforms (12) Stairs have handrails in child's reach to ages on license c. Current license/permit posted (13) Smoking prohibited during hours of care The Home(II. C.,pages 16-24) (14) Clear glass doors marked at child level 1. Indoor area(II.,C.,pages 16-20) (15) Tools and machinery inaccessible V a. Injury prevention(II.,C.,2.,a.,pages (16) Hot tubs covered or drained during hours of 16-17) care ]� (1) Home free of apparent hazardous (17) Working flashlight conveniently located 0 conditions (2) Home has electricity,water,gas,waste (18) Consumption of alcohol prohibited during disposal O hours of care (3) Home has working telephone ,,.-y (19) Non-prescription narcotic or illegal substances (� prohibited (4) Dangerous substances locked p—� b. Cleanliness and health(II.,C.,2.,b.,pages 17- V 18 (5) Aggressive animals not kept rj (1) Bathroom clean (6) Animals that pose a threat kept away ,' (2) Foot stools for handwashing and toileting O from children S (7)Fans in reach of children enclo9home JJJ (3) Potty chairs(if used)emptied,washed, disinfected after each use (8) Electrical outlets covered (4) Rodent/insect infestation prevented/eliminated s Are any guns or firearms kept in the (5) Garbage and trash stored in covered water-tight, on the premises? fly-proof containers and removed regularly Yes ❑ No O Page 1 of 8 (, U REGULATIONS cc sg m REGULATIONS (a CL Q E E a o 0 E E a 0 Q U o 0 0 0 Z Z Z Z (6) Bedding,toys,utensils,toilets,sinks (17) Waterbeds not used by a child used by a sick person cleaned and disinfected before use by=other person (7) Windows and doors used for (18) Upper/top bunk beds not used by a child ventilation screened (' c. Space II.,C.,2.,c.,page 18 (19) No child sleeps/naps on floors (1) Rooms well-lighted,ventilated, 2. Outdoor area(H.,C.,.pages 20-22) comfortably cooled or heated as appropriate Q to the season (2)Space for providing privacy to a child in a. Outdoor play area(pages 20-21) care and members of the household as `^ needed v (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 18-20 (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 d protruding edges(except where prohibited by federal r law) V (2) Number of cribs that meet the US (4) Outdoor play equipment not designed to be D Consumer Product Safety Act of 2008: portable,anchored 3 Number of playpens: (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 playpen (6) Crib slats no more than 2 3/8 inches b. Injury prevention(page 21) 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 (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 S inaccessible to children or may sleep alone (11) Beds,cribs,cots,or playpens clean c. Swimming and wading (pages 21-22) and sanitary and free of hazards,maintained in good condition (12) Bedding adequate,appropriate to `^� Is there a pool on the prem'ses? season v Yes ❑ No (13) Sheets and covers laundered weekly (1) Swimming pool 2 feet or more in depth, or more often when soiled 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 Page 2 of 8 U U REGULATIONS CU !M ca REGULATIONS 0 .Q c0i E E Q E o CL o U " Q U o a o Z Z ZI Z Do children in care use the 19 . j. Each child younger than 1 year or weighing less ❑ Yes No 0' than 20 pounds secured in infant only or convertible seat used in rear-facing position (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 2�/2 booster seat (b) One adult to three children 2'/2 to 6 in. No child transported in front seat of vehicle with ears passenger-side air bag (c) One adult to five children 6 years and V older !' (4) Person with current American Red 4. Emergency Procedures(pages 23-24) Cross Lifeguard Training certificate in pool area at all times pool is in use (5) Copy of Lifeguard Training Certificate Licensee and each caregiver has current infant-child on file in home CPR and first aid certificate/co ies on file in home (6) Wading structure less than 2 feet in Licensee and Members of the Household(II.,D., depth,has continuous adult supervision pages 25-31) 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 31) (8) The licensee is present during any Care of the Children(II.E.,pages 32-39) swimmin wadin activities 3. Transportation(pages 22-23 1. Su ervision of the Children a e 32 Does the licensee provide transportation a. Children supervised at all times for children in care? S 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 M from the home activities. \_ /` a. Licensee responsible for children they 2. Infants and children handled gently(page 32) transport b. Licensee responsible for picking child up 3. Health(pages 32-34) 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 r�/, ,5 checked) /" d. Written consent to transport child (1)No ill child admitted to home e. No child left unsupervised in vehicle (2)Ill,injured child separated from group but Ix 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 procedures9 Yes No ❑ C.Medication/medical procedures administered only with written authorization from parent Page 3 of 8 REGULATIONS m coo REGULATIONS co ca Q E o Q E o CL O v Q U U Q U o 0 0 Z Z Z Z (1)Blanket authorization forms are Menu or food served on date of visit if observed: prohibited - (2)Prescription or over the counter drugs in d. Small,hard candies or nuts not served to children original container 5 younger than 4 years S (3) Prescription drugs have pharmacy label If e. Foods that may cause choking prepared c or written physician's written instructions appropriately for the children (4) Over-the—counter drugs labeled with f. Foods served only under close supervision as child's name and directions required (see page 36) 4. Care of Infants (pages 34-35 7. Food Service (page 37 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 5 otherwise 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 c.Diapering area washable,cleaned and c. Formula and food brought from child's home 5 disinfected after each use labeled and stored properly d. Soiled diapers disposed of in plastic-lined V d.Each infant held for bottle feeding/No bottles containers propped e.Licensee/caregivers wash hands with soap e. Each child seated while eating and warm running water after diapering each child,assisting with toileting, and contact with bodily fluids f.Individual disposable paper towels used L] 9. Personal Belongings (page 38) 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 S b. Sufficient clean, dry diapers and clothing p provided for each infant/toddler i.Diapering area separate from food service, c. Space for each child for storing personal preparation,and storage areas belongings j. Infants handled gently,each infant's head 10. Sign in/Sign out Procedures (page 39) supported,rough or harsh handling S prohibited 5. Child Abuse/Neglect Reporting(pages a. Each child signed in at arrival 35-3 a. Known or suspected Child Abuse/Neglect c b. Each child signed out at departure reported as required J b. Child abuse/neglect reports confidential 11. Release of Children(page 39 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 36-37) b. Photo ID required for unfamiliar persons picking up a child a. Meals and snacks provided as required 5 Administration II.,F.,pages 40-44 b. Formula or food for infants&other 1. General administrative responsibilities (pages special diets prepared as directed or provided C 40-41) by parent/guardian J c. Formula,powder or concentrate,shall be a. Current license/permit posted prepared by parent Page 4 of 8 ° U U U: U REGULATIONS m a REGULATIONS ( c. C.)QQ Q .2 a n O U Q O U Q o 0 0 Z Z Z Z b. Most recent licensing evaluation posted O d. Certificate of rabies vaccination c. Corrective/adverse action notices posted e. Children's records complete(see checklist) d. Most recent deficiency report posted f. Transportation checklists kept for current year —_plus two additional years e. Public notice form posted g. Sign in/sign out sheets kept for current year plus two additional years . . f. .Licensee's social security number G. Nighttime Care(page 45) available to parents on request This section to be completed for homes providing care after 7 .m. 2. Reports to the Department(pages 41- 1. Number and age range of children does not 42) exceed number and age range on license/permit b. Child abuse/neglect reported as required 2. Bathing (page 45) 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 b. Each child bathed separately professional medical treatment (2) Any illness/injury requiring emergency c. Each child supervised while bathing medical treatment (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 4 (6) Change in name or number of street [ a. Each child younger than 18 months,sleeps alone address 7 in crib (7) Change in telephone number b. Number of cribs that meet the US Consumer Product Safety Act of 2008: (8) Serious accident or illness of the c. Infants placed on back to sleep licensee or members of the household (9) Serious damage to the home or grounds 5, d.Each child 18 months and older sleeps in abed (10) Changes in members of the household e. Number of beds: (11) Any arrest of licensee,household 4. Each child's toilet articles labeled with name, P� member,caregiver,substitute kept separate,kept in sanitary condition J (12) Final disposition of any child 5.,Breakfast served to each child who goes directly abuse/neglect investigation involving to school unless provided by school or parent licensee,household member,caregiver, �Q substitute / d. Physical/structural changes to home or 6. Evening meal provided for each child continuing 5 grounds reported in advance from day time care e. Any change,in location reported in H. Group Day Care Homes(pages 46-47) This- advance (New license is required) S section to be completed for homes providing care for 7 to 12 children. 3. Records to be kept by the licensee 1. At least two adults present and supervising the (pages 42-44) children when seven of more children are present a. Record for licensee/household members 2. If a substitute is used,the licensee or assistant (see checklist) caregiver is present b. Records.for caregiver/substitute(see 3. Complete record for assistant caregiver checklist) c. Records on caregivers/substitutes kept at 5 4. Outdoor play area fenced least two years after person leaves Page 5 of 8 REGULATIONS c�v v REGULATIONS ` J co CIS E E Q E o a p V Q U U Q U c o p Z Z Z Z I. Group Nighttime Homes(page 48) This section to be completed for homes _ providing care for 7 to 12 children after 7 .m. 1. At least two adults present and supervising the children when seven of more are resent 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. ature of licensee or designated staff. Date Page 6 of 8