Evaluation Form (3) � 1/19
ALABt.�AA DEPARTMENT OF HUMAN Rol oOURCES
t CHILD CARE HOME LICENSING EVALUATION
Short Form
Licensee: Dates of Evaluation: D ��
Name of Facili Date(s) of Follow-up:
—Address:—�3'm Purpose of Visit:
y Telephone#: 0.2
Day Care ❑ ffighttime Care ❑ Fami1v VGroupub •d
Licensed Capacity: Da /oA Night A e Ran e: Da ..r Nigh
Days of Operation: Day A4,jE Night Hours of Operation: I Da A_. •,%` Ni ht
License Number: 7 to ep C2 Do Codes: �'�►
Effective Dates of License: O—Observed by DHR Licensing Representative
From: 3 To• ® S—Certified by Licensee
D—Discussed with Licensee
County: 0!0�� X—Not Applicable-Not reviewed with Licensee
Deficiencies Noted: PrYps ❑ No DHR nsing Representative:
� t
Sections to be completed at the discretion of the DHR Licensing Representative. 1
U v a)REGULATIONS 8 REGULATIONS m M
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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 ca aciguns/firearms in locked storage
b. Ages range of children in care conforms L (12) Stairs have handrails in child's reach
to ages on license tJ
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 (�
a. Injury prevention(II.,C.,2.,a.,pages (16) Hot tubs covered or drained during hours of x
16-17 care
(1) Home free of apparent hazardous D (17) Working flashlight conveniently located
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conditions
(2) Home has electricity,water,gas,waste (18) Consumption of alcohol prohibited during
disposal
hours of care
(3) Home has working telephone ® (19) Non-prescription narcotic or illegal substances
prohibited
(4) Dangerous substances locked b. Cleanliness and health(II.,C.,2.,b.,pages 17-
18
(5) Aggressive animals not kept (1) Bathroom clean Q
(6) Animals that pose a threat kept away 7 (2) Foot stools for handwashing and toileting
from children
(7)Fans in reach of children enclosed (3) Potty chairs(if used)emptied,washed,
disinfected after each use
(8) Electrical outlets covered (4) Rodent/insect infestation prevented/eliminated
Are any guns or firearms ept in the home or (5) Garbage and trash stored in covered water-tight,
on the premises? fly-proof containers and removed regularly
Yes ❑ No
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(6) 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
(7) Windows and doors used for (18) Upper/top bunk beds not used by a child
ventilation screened
c. Space I.,C.,2.,c.,page 18 (19) No child sleeps/naps on floors
(1) Rooms well-lighted,ventilated, 2. Outdoor area(II.,C.,pages 20-22)
comfortably cooled or heated as appropriate
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
(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 protruding edges(except where prohibited by federal
law)
(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: H (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 S (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, O
uncovered wells and cisterns, stacked lumber with
ex osed.nails,explosives
(8) No infant put to sleep on sofa, soft (2) Tools and machinery inaccessible to children
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 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' ?
season Yes ❑ No 01
(13) Sheets and covers laundered weekly GJ (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
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Do children in care use th ool? j. Each child younger than 1 year or weighing less
Yes ❑ No than 20 pounds secured in infant only or convertible
seat used in rear-faciaposition
(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 y
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
older ::�6
(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 J(
(5) Copy of Lifeguard Training Certificate Licensee and each caregiver has current infant-child
on file in home l� CPR and first aid certificate/copies on file in home
(6) Wading structure less than 2 feet in Licensee and Members of the Household(H.,D.,
depth,has continuous adult supervision �. pages 25-31) See checklist
(7)Wading structure/pool filled with clean L Licensee does not work or attend school during
water each day,emptied when not in use 7 hours of child care (page 31)
(8) The licensee is present during any S Care of the Children(II.E.,pages 32-39)
swimming/wadingactivities
3. Transportation(pages 22-23 1. Supervision of the Children(page 32
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 32)
transport
b. Licensee responsible for picking child up _ 3. Health(pages 32-34)
at the designated location and delivering the Y
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)Ill,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/medical procedures administered only
with written authorization from parent
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(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 younger than 4 years
(3) Prescription drugs have pharmacy label e. Foods that may cause choking prepared
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 (seepage 36)
4. Care of Infants(pages 34-35 1. 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 S with soap and warm running water as required
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 e
disinfected after each use labeled and stored properlyJ
d. Soiled diapers disposed of in plastic-lined 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 S
with bodily fluids
f. Individual disposable.paper towels used 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 b. Sufficient clean,dry diapers and clothing
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)
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supported,rough or harsh handling
prohibited
5. Child Abuse/Neglect Reporting(pages a. Each child signed in at arrival
35-36
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 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
ip a child
a. Meals and snacks provided as required 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 40-41)
byparent/guardian
c. Formula,powder or concentrate,shall be a. Current license/permit posted
prepared by parent
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b. Most recent licensing evaluation posted S d. Certificate of rabies vaccination
c. Corrective/adverse action notices posted e. Children's rec r s cc% hte(see ch c�kli )
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 L This section to be completed for homes providing
,J care a ter 7 .m. 'lcrr+u•w4+ NT 1 i
2. Reports to the Department(pages 41- 1. Number and age range of childreTt does not
42) exceed number and age range on license/permit S
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 S 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 S
for each child
(4) Changes in caregivers or substitutes
5) Change in licensee's name 3. Sleepingre uirements (page 45
(6) Change in name or number of street L a. Each child younger than 18 months sleeps alone
address 7 in crib
(7) Change in telephone number C b. Number of cribs that meet the US
.7 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 d.Each child 18 months and older sleeps in a bed
(10) Changes in members of the household S e. Number of beds:
(11) Any arrest of licensee,household 4. Each child's toilet articles labeled with name,
member,caregiver,substitute kept separate,kept in sanitarycondition
(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,
substitute
d. Physical/structural changes to home or 6. Evening meal provided for each child continuing
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) 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 4. Outdoor play area fenced
least two years after person leaves
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I. Group Nighttime Homes(page 48)
This section to be completed for homes
providing care for 7 to 12 children after 7
P.HL
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.
Sign re of licensee or designated staff Date
Page 6 of 8
-` Equipment Checklist
Codes: Use the following code when completing the columns for each category.
( O ) indicates compliance observed
(q) 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 2% markers,paper,chalk,blunt-end
1. Equipment for Children scissors,paste,glue,playdough,
Up to 2r/a Years Years u to 6 Years paints(tempera or water color),
a. Toys for Active/Outdoor long handled brushes,finger paints
• . A variety of age-appropriate books. Toys For
Play
Play Sand or digging area with items for accessible to the children
A device that plays a variety of age-
Small wheel toys digging,filling,sifting, d pouring
Push and pull toys Climbing structure with soft appropriate instruments
music
Rhythm ins
Boxes of assorted sizes
surface underneath
Wheel toys f. Nature and Science
Swings with safety seat,infant swing
Buckets for water play,items for Materials
Sand or digging area, toys for ourin ,measuring,floating Collections of rocks,leaves,seeds,
digging,pouring,siftingC�
Large Balls ' ' ' • etc.
Puzzles Aquarium with fish (must be
b Quiet Beads or spools and string for covered
Simple puzzles stringing C;> Magnifying glass
Nesting and stacking toys Peg boards and pegs Magnets
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
Creative construction sets Years and Older
Picture books
BlocksStorage
c. Art materials Small cars,trucks,boats,trains Children shall have a separate area
Paper for storing their personal items and
Non-toxic crayons Make-believe projects
Non-toxic water color markers Dolls,with clothes,blankets,
b. Art, Music, Books
Non-toxic play dough storage areaDoll stroller Non-toxic art materials:a variety of
kinds of paper, scissors, glue,
d . toys Doll bed or cradle crayons, markers, chalk, paints,
Crib mobiles(for infants younger Dress-up clothes clay,playdough
than 5 months) Home living area-kitchen Books and magazines appropriate
Washable teething rings appliances may be purchased or to the ages of the children
made from cardboard boxes A device that plays a variety of age-
Rattle toys
Play dishes,plastic baby bottles, a ro riate music and stories
Squeeze toys pot s and pans,measuring spoons c. Dramatic Play Props-,
Soft cuddly toys Puppets Dress-up clothes
Busy boxes Sheet or bedspread for making a Dolls and dolls clothes
e. Make-believe Play tent Costumes and masks
Dolls,and clothes and blankets Cardboard boxes in assorted sizes
Dress up clothes Mirror d. Toys for quiet time 11
Interlocking manipulative play sets
Homelivin area-pretend kitchen Toy telephone
g area-P ® Jigsaw puzzles
appliances may be made from d. Water Play Board games and playing cards
Toys,dishes,pans,spoons,plastic ® Dish pan
containers with lids Equipment '
Sponges e.
Toy telephone Active/Outdoor
Puppets Bubble mixture Balls
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Strainers
Funnels Bats r"
Egg beaters Tether ball
Small boats and other floating toys Croquet set
e. Art, Books, Music Badminton set
Non-toxic art materials-large Horseshoes
pencils and crayons,water color Wheel toys
10