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Evaluation Form (4) R vised 3/2020 ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HOME LICENSING EVALUATION u ANNUAL Licensee: ' *. Wtkhool Can Dates of Evaluation: �p Name of Facility: Date(s) of Follow-up: Address: `Z,.b O�r-kex- P*-t►reWi6 ® Purpose of Visit: z`0 bte ® Telephone#: —1 4 r [XDay Care ❑ Nighttime Care Family ❑ Group ❑ Subsidy Licensed Capacity: Day LP Night A e Ran e: I Days of Operation: I Da Night Hours of O eration: I Da i lit License Number: Codes: Effective Dates of License: O—Observed by DHR Licensing Repre enta�tive S—Certified by Licensee From: 1' b To: .021D—Discussed with Licensee County: Dole. le - X—Not Applicable-Not reviewed with icensee Deficiencies Noted: Yes ❑ N R 'censi epresentative• }� :\o 2S 20 20 Sections to be complete at the discretion of he DHR icen ng Representative. (D a) (D aQ (I a� REGULATIONS c C m REGULATIONS C c n cQ — U CU U Q _ E O U Q O � Q CL Z Z o Z Z Licensing Procedures(II.,B.,pages 11- (10) Gun firearms in locked storage • 14 �,,, 1. Provisions of license/permit(II.,B.,7., (1 ) Ammunition stored separately from pages 12-13guns/firearms in locked storage a. Number of children in the care of the 02) Stairs bave 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 ZD 1. Indoor area(II.,C.,pages 15-19) (16) Ho tubs c vergd or ra' ed during hours of care -� a. Injury prevention(II.,C.,2.,a.,pages (17) Working flashlight conveniently located 15-16 (1) Home free of apparent hazardous (18) Consumption of alcohol prohibited during conditions hours of care (2) Home has electricity,water,gas,waste �.J (19) Non-prescription narcotic or illegal substances disposal q,J prohibited (3) Home has working telephone ® (20)Bio contaminants shall be stored and disposed of properly (4) Dangerous substances locked b. Cleanliness and health(II.,C.,2.,b.,pages 16-17) (5) Aggressive animals not kept (1) Bathroom clean (6) Animals hat posek a threat (2) Foot stools for handwashing and toileting from children ft (7)Fans in reach of c e enc osed (3) Potty chairs(if used emptied, ashed disinfected after each use Wf� (8) Electrical outlets covered ® (4) Staff shall use Universal Precautions when diapering or being exposed to bodily fluids Are any guns or firearrqsypt in the home or (5) Rodent/insect infestation prevented/eliminated on the remises? Yes No ❑ (9) Guns/firearms unloa ed (6) Garbage and trash stored in covered water-tight, fly-proof containers and removed regularly REGULATIONS QvREGULATIONScc c M rL E — E n- Q- a O rL E Q 0 o C U C' o c �' Z Z O 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 b another person j; (8) Windows and doors used for (18) Upper/top bunk beds not used by a child ventilation screened 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 0 (3)Clean,appropriate facilities for (1) Children supervised at all times rotection,storage,preparation of food d. Equipment and furnishings(II.,C., (2) Outdoor play area free from apparent hazards 2.,d., pages 18-19) 0 (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 Consumer Product Safety Act of 2008: portable, anchored 3 Number of playpens: 5 Concrete or asphalt not used under a ui ment (4) No child shall sleep with an adult (6) Area free of stacked lumber,construction materials,firewood __A) (5) Each child younger than 12 months (7) Stairs/steps have hand rails in child's reach I sleeps alone in a crib or playpen (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 j mattress or other soft surface (9) Each child 12-18 months sleeps alone (3 All poison ke t ' cked area in a crib,play pen or a low cot (10) Two children over 18 months of the ( ater hazards on or adjacent to home same sex may share a double or larger bed inaccessible to children or may sleep alone V (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 pQoi on the premises? season Yes D5, 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 whep�_V ol is not in us beds covered with clean linens before used �� 1 b children in care �' `�'�' (O - I 2 REGULATIONS cu 0 ° Qa REGULATIONS Ic�a -UMu a cU CL Q CL Q U Q U Q w, o 0 io 0 Z Z Z Do children in care us t Uh 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-facing position j (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 j (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'/a to 6 in. No child transported in front seat of vehicle with ears passenger-side air bap- (c) One adult to five children 6 years and older (4) Person with current American Red 4. Emergency:-Preparedness.an esponse Plans Cross Lifeguard Training certificate in pool (pages 2�3�24), } ' ` � .: area at all times pool is in use See Checklist page 9 (5) Copy of Lifeguard Training Certificate \A Licensee and each caregiver has current infant-child on file in home 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.,D., depth,has continuous adult supervision pages 25-33) See checklist (7)Wading structure/pool filled with clean G Licensee does not work or attend school during water each day, emptied when not in use J 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(pages 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 H man b. Licensee responsible for care and supervision at Resources does not inspect activities away all times el 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 34) transport "'YS I � I 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 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 ZS 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 3 REGULATIONS (ac VT a REGULATIONS M oE D_ AZ a0 Q Q 0 ZZ (1)Blanket authorization forms are Menu,or food served on datLqof 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 see page 36 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 5 with soap and warm running water as required otherwise I b. Soft materials, including pillows,quilts, b. Individual, disposable paper towels used for hand comforters, sheepskins,bumper pads,stuffed S drying toys prohibited in sleeping environment c.Diapering area washable,cleaned and 15 c. Formula and food brought from child's home disinfected aftereach use labeled and stored properly d. Soiled diapers disposed of in plastic-lined d.Each infant held for bottle feeding/No bottles containers propped 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 c b. Sufficient clean, dry diapers and clothing �7provided for each infant/toddler i.Diapering area separate from food service, ® c. Space for each child for storing personal re aration, and storage areas belongings 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) - 0 a. Known or suspected Child Abuse/Neglect b. Each child signed out at departure reported as required tle>I �P I b. Child abuse/neglect re orts confidential 11. Release of Children a e 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 u a child a. Meals and snacks provided as required Administration I.,F., pages 41-45 b. Formula or food for infants&other 1. General administrative responsibilities (pages special diets prepared as directed or provided 41-42) by parent/guardian c.Formula,powder or concentrate,shall be C a. Current license/permit posted prepared by parent `J i i 4 i REGULATIONS C m M REGULATIONS �_ m Q U Q a Q a + U Q U QCL U p O p O 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 posted 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 checklist&kept for currentyear plus two additional years f Em ency Preparedness-and-gespons-e7—, g. Sign in/sign out sheets kept for current year plus Puri ostedk- _ �,`;., two additional years g .Licensee's social security number G. Nighttime Care(page 46) available to parents on request This section to be c leted fio care a ter 7 .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 i 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 b. Each child bathed separately professional medical treatment j (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 I I—x 4 Changes in caregivers or substitutes f 5 Change in licensee's name 3. Sleeping requirements (page 46 (6) Change in name or number of street a. Each child younger than 18 months sleeps alone address in crib (7) Change in telephone number b. Number of cribs that meet the US ` Consumer Product Safety Act of 20W: �•.]• (8) Serious accident or illness of the c. Infants placed on back to sleep j licensee or members of the household 9 Serious damage to the home or grounds d.Each child 18 months and older slee s in a bed (10) Changes in members of the household e. Number of beds: n l� �'R (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 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 daytime care d. Physical/structural changes to home or H. Group Day Care Homes(pages 47-49) grounds reported in advance This section to be completed for homes providing care for 7 to 12 children. e. Any change in location reported in 1. At least two adults present and supervising the advance New license is required children when seven of more.children are resent 3. Records to be kept by the licensee 2. If a substitute is used,the licensee or assistant (pages 43-45 care iver is resent a. Record for licensee/household members 3. Complete record for assistant caregiver see checklist b. Records for caregiver/substitute(see 4. Outdoor play area fenced checklist I 5 i .;* a. c ILt REGULATIONS OREGULATIONSa 1== o QUQ Q0 O Z Z O Z I. Group Nighttime Homes(page 50) 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 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 advers action. None of these requirements are to be interpreted to allow anyone to operate in violation of the Minimum Standar s. A facility licensed by the Department must meet Minimum Standards at all times. It is the responsibility of the licensee to o Crate in compliance with the Minimum Standards. Signature of licensee or des gnated staff Date I i i i f i 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 fil ) I 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 Blizzards Ice storms Earthquakes Lockdown or evacuation due to threats of violence Location and use of fire extinguishers / Evacuations due to; f #Documentation of the following quarterly drills; j Hazardous materials t Fire Spills ` Tornado Gas leaks Bomb threats Lockdown Fire Relocation I Infectious disease emergencies P"` 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 The disaster plan shall include details for: The Emergency Preparedness and Response'Plans ld be: Shelter in place or evacuation Available to all staff and employees Assisting infants and children with special needs and/or Ith Posted in a Conspicuous place conditions Reunification with parents Submitted to the Department Supplies needed for shelter in place procedures UO- Copies provided to all parents/guardians `- 4 i Transportation disaster procedures ,A1 Staff training/reassignment as appropriate r i #Plan updated yearly Contact with local emergency management officials I i 7