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Evaluation Form (7) Revised 3/2020 - ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HOME LICENSING EVALUATION RENEWAL Licensee: Date(s) of Evaluation:t )n- nnV �11mith . 9_D Name of Facility: Date(s) of Follow-up: onn 0J car& Add r s/Co;finty: Purpose of Visit: _ Telephone #: ) ) RDay Care Ni;htt me Care �iamily ❑ Group Subsidy Licensed Capacity: Day xi Age Range: Da 114 0 Night Days of Operation: D L, Nigh Hours of Operation: Day Night e ca m p License Number: Codes. 0. N 41 O-Observed by DHR Licensing Representative Effective Dates of License: S—Certified by Licensee D—Discussed with Licensee F'rom:10"2__191 To: ' X—Not Applicable-Not reviewed with Licensee Deficiencies oted: [ 'Yes ❑ No DHR Licensing epresentative: a Sections to be completed.at the discretion of the DHR' /icensing Representative. U U U U REGULATIONS M REGULATIONS � �CL M E o E a U Q ° o Q z Z o 0 z Z Licensing Procedures(II., B., pages 11-14) (4) Dangerous substances locked 1. Provisions of license/permit(1I.', B.,7., (5) Aggressive animals not kept pages 12-13) a. Number of children in the care of the licensee does (6) Animals that pose a threat kept away from not exceed licensed capacity. 0 children b. Ages range of children in care conforms to age on (7)Fans in reach of children enclosed license. c. Current license/permit posted. (8) Electrical outlets covered �] The Home(II. C., pages 15-24) Are any-unsor firearms kept in the home or on 6/ the premises.) f 1. Indoor area (II.,C., pages 15-19) Yes Erle No ❑ a. Injury prevention(II.,C.,2.,a.,pages 11-16) (9) Guns/firearms unloaded (1) Home free of apparent hazardous conditlions In I (10) Guns/firearms in locked storage i (2) Home has electricity,water,gas,waste dispo al (11) Ammunition stored separately from Ij guns/firearms in locked storage i (3) Home has working telephone 0 (12) Stairs have handrails in child's reach ey REGULATIONSREGULATIONS . 0 E 0 Q 0 U Q 0 U Q U U 0 0 0 0 Z Z Z Z (13) Smoking prohibited during hours of care (3) Number of playpens: (14) Clear glass doors marked at child level' (4) No child shall sleep with an adult. (15) Tools and machinery inaccessible (5) Each child younger than 12 months sleeps alone in a crib or playpen. (16) Hot tubs covered or drained during hours o care (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 h ours (8) No infant put to sleep on sofa,soft mattress , of care i or other soft surface. (19) Non-prescription narcotic or illegal su6stan es (9) Each child 12-18 months sleeps alone in a prohibited crib,play pen or a low cot. (20)Bio contaminants shall be stored and dispose of (10) Two children over 18 months of the same properly sex may share a double or larger bed or may sleep alone b. Cleanliness and health(II.,C.,2.,b.,pages 1�5-17) MI (11) Beds,cribs,cots,or playpens clean and sanitary and free of hazards,maintained in good (1) Bathroom clean condition (2) Foot stools for handwashing and toileting (12) Bedding adequate,appropriate to season (3) Potty chairs(if used)emptied,washed,disin cted (13) Sheets and covers laundered weekly or after each use i ( more often when soiled. (4)Staff shall use Universal Precautions when (14) Number of beds: diapering or being exposed to bodily fluids j (5) Rodent/insect infestation prevented/eliminate (15) Number of cots: (6) Garbage and trash stored in covered water-tig t, (16) When not in use by family members,beds fly-proof containers and removed regularly j1 covered with clean linens before used by children �1 in care. (7) Bedding,toys,utensils,toilets,sinks used by (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 (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. cooled or heated as appropriate to the season (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 children (3) Clean,appropriate facilities for protection, (22) All material with sexually explicit, storage,preparation of food. frightening,or.violent content kept inaccessible to children d. Equipment and furnishings (II.,C.,2.,d.,pages 2. Outdoor area(II.,C.,pages 20-21) I 18-19) (1) Crib,bed,playpen or cot provided for each cf ild for rest/sleep during hours of care. i J (2) Number of cribs that meet the US Consumer Product Safety Act of 2008: f 2 REGULATIONS REGULATIONS Q E Q E t1 0 O E O 0 Q O Q U o 0 00 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 (_) Outdoor play area free from apparent hazard g1 (6) Wading structure less than 2 feet in depth, JJ has continuous adult supervision (3) Fence at least 4 feet in height, free from sharp, (7)Wading structure/pool filled with clean protruding edges (except where prohibited by federal water each day,emptied when not in use I aw) (8) The licensee is present during any swimming/wading activities (4) Required outdoor equipment provided (See 3. Transportation(pages 22-23) equipment checklist for details) 10 (5) Outdoor play equipment not designed to be Does the licensee provide portable,anchored transportation for children in care? (6) Concrete or asphalt not used under equipment Yes ❑ No 2,/ (7) Area free of stacked lumber,construction NOTE: The Department of Human Resources materials,firewood does not inspect activities away from the home. The licensee shall assume full authority and (8) Stairs/steps have hand rails in child's reach responsibility for away from the home activities. b. Injury prevention(page 20) a. Licensee responsible for children they transport :X1 (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 to the care of the designated person exposed nails,explosives (2) Tools and machinery inaccessible to children C. Transportation Checklist used for transporting by vehicle or walking(Sample checked) (3) All poison kept in locked area d. Written consent to transport child (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 ❑ NoMJ (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 o belt or child restraint which is properly anchored doors,windows,or other openings to the vehicle,installed and used according to (2) Swimming pool has locking gate. Gate and o her 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 Yes ❑ No . system appropriate to age and size (3) Adult to child ratio in pool area: s j. Each child younger than 1 year or weighing j less than 20 pounds secured in infant only or (a) One adult to each child younger than 2 I_ convertible seat used in rear-facing position (b) One adult to three children 2'/ to 6 yearis i. Each child younger than 6 years or weighing (c) One adult to five children 6 years and older less than 40 pounds secured in forward facing seat 3 Q REGULATIONS M M REGULATIONS ❑. — Q, Q 0 0O Q O rZ Q U 0 Q U Q 0 = o Z° Z Z Z k. Each child younger than 6 years secured in a booster (5) If parent/designated person cannot be reached,or if seat illness/injury is severe,licensee shall obtain emergency treatment 2 1. Each child 6 years and older secured in an,indi-vidual (6) Parent urged to notify licensee if child is exposed to seat belt. contagious disease will m. 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 ResponsciPlan c. Medication/medical procedures administered only (pages 23-24) 1 "ten authorization from parent See Checklist page 11 1 ® / s a. Emergency list posted by the phone (1) Blanket authorization forms are prohibited b. Substitutes/caregivers informed of responsibilities in (2) Prescription or over-the counter drugs in original emergency container c. Licensee and each caregiver has current irifant- hild (3) Prescription drugs have pharmacy label or written CPR and first aid certificate. Copies on file in home physician's written instructions Licensee and Members of the Hous.ehc ld rV the-counter drugs labeled with child's name (II.,D.,pages 25-33) See checklist e-7 A ections 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 Care of the Children (II. E., pages'3440) (8) Time and date of medication documented in writing and kept in child's file in home i 1. Supervision of the Children(page 34) (9) Copies of documentation available to parents on request a. Children supervised at all times. ! limp 4. Care of Infants(pages 36-37) b. Licensee responsible for care and supervision al 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 3 ) b. Each infant placed on stomach part of time he/she is 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 a rival d. Soft materials,including pillows,quilts,comforters, sheepskins,bumper pads,stuffed toys prohibited in J� b. Illness,injury,change in health reported to pare it sleeping environment (1) Exposure to contagious disease reported.to pe rent e. Diapering area washable,cleaned and disinfected after each use. (2) No child who is ill admitted to home f. Clean diapers and clothing provided for infants/toddlers. (3) III,injured child separated from group but g. Wet,soiled diapers and clothing changed promptly continuously supervised (4) Ill or injured child's parent notified immiediat ly h. Soiled diapers disposed of in plastic-lined containers and required to come for child or arrange for designated person to come for child I 4 U U a) U a) Sa REGULATIONS C: m Q — Q a. — E E a E E Q Q U °�, Q O ° Q Z z Z Z i. Licensee/caregivers use Universal Precautions fter b. Individual,disposable paper towels used for diapering or assisting with toiletin&and contact ith hand drying bodily fluids Im,! j. Individual disposable paper towels used for hand c. Feeding chairs provided for infants drying k. Clean disposable gloves used for diapering eac�l d. Feeding chairs and tables cleaned and f child disin cted before and after meals and snacks 0 1. Each child's hands washed after diapering e. Each child's food served from an individual dish m. No child left unattended while being diapered f Each infant/toddler 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 supp rted, h. Disposable utensils and cups used only under 11 rough or harsh handling prohibited. close supervision 5. Child Abuse/Neglect Reporting(page 37) i. Formula and food brought from child's home labeled and stored properly a. Known or suspected Child Abuse/Neglect repo, ed j. Milk and formula refrigerated immediately as required. 1/ b. Child abuse/neglect reports confidential k. Previously opened baby food jars not accepted c. Licensee,caregivers,and household members I. Formula left in bottle after feeding discarded cooperate with DHR on any child abuse/neglect investigation,including providing information& m. Each infant held for bottle feeding. No bottles allowing access to children and records. propped. 6. Meals and Snacks(pages 33-39) n. Size of servings adequate to meet child's needs a. Meals and snacks provided as required. o. Food not forced or withheld Me u or food served on date of visit if observed: �)) j,a�� p. Each child seated while eating (.fs ' � � S. Food protection and preparation(page 39) b. Formula or food for infants other special diets a. Food in good condition prepared as directed or provided by parent/guardia c. Special foods for children labeled with child's n me b. No home-canned foods used and stored as directed d.Formula,powder or concentrate,shall be prepared by c. Food protected from contamination parent ed Fluid milk served. No powdered milk used for J'1 d. Food preparation surfaces and utensils cleaned drinking �,f before and after use f. Small,hard candies or nuts not served to childre 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 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 7. Food Service (pages 38-39) h. Floors in food preparation and service areas swept or vacuumed daily,mopped as needed a. Licensee,caregivers,each child washes hands w th soap and warm running water as required 5 9 S1Uana snoilsustP Auy(£I) palsod ltuuad/asuaoq lualmo •u alnlpsgns`Jantoaiea`jagwow plogosnoy aasuaog SUTAJonut uoUEttlsanw loaltaupsnqu (Z6-I17 pJtgo Wu do uotltsodstP IEutd (Z I) sated) saplitgtsuodsai antlEllstutwpe JE.tau30 •I alnitlsgns`Janitaleo �agwaw plogasnoy`aasuao113o lsaue Cuy (l I) (ct,-Iv satud ` `-II) uorle.11slumpd ployasnoq agl3o siagwaw ut saoueg0 (OI) . itstA of]ytu3o pauvodut sluaJEd q spunaa io awoy agl of atEutEp snouts (6) awtl AuE lu 1tstA of lyau anuq sl=ud •E plogosnoq aql jo slagwow 10 aasuootl ag13o ssaulp jo luaptoou snouaS (8) (ph aged)suEtpEnt/sluaaud Aq sllstA 3'I �p Pltgo u iagwnu auogdalal ut zSuego (Z) t" do SuPlatd suoslad lEytwE3un lo3 pannbal QI oloyd 'q F lualEd wo13 uotlezuoylnE ssalppu laails 3o iagwnu Jo awuu Ut a,-LID (g) uallum lnopm auo4uE of posealai pligo ON -u -own s,aasuoog ut 32uugD (5) (of aped)uaIpl!gD}o asealag '£I salnitlsgns to slanttaiuo ut SQSUeq:) (b) ainwdop m lno pauots pltgo gou3 'q owoq ogl ut ouwn000 yluap AuV (£) Junwe lu ut pauots Pltgo 113E3 'E luawlua.tl luotpow doua nwo Suutnbai tinfut/ssaulit!Uy (Z) (of ated) saanpaaoid lno uttS/ui uttS -ZI luatulEwl lEotpaw I slluwad iEuotssa3oid tuumbai 6mfut/ssaulit Aw (I) �aitIvom uogm`,Cup goEa sioopino owp puads ualpl!40 :sAvp g utglim nodal uouum`smoq bZ uNI'm 2IHQ of pavodoi luimolloj all -o (or atud) Xuld aoopin0 •I I MEl !q pannbal se pahodai laal2au/asngE pitqD •q paltgtyojd outlpuEq gsleq io gono-d -e polsonbol su polltwgns sliodai luawllolu3 •u pinlo jaglouu,Cq pajalstutwpu luawgstund ON 3 sated)luawl ndaQ aql of slaodali •Z luawgstund su lulEllsai Juats/Cgd ON a lsanbai uo sluond salnpaoold woozyluq of alqupAu 1agwnu Awnoas lumos s,aasuaorl f ao`sduu`poo3 qpm powposse lou awldtosta •p satotlod puu solni M uallu ut saouEgo3o pagtlou 2[HQ puu slualud I osnqu leq.taA ON .o palloaua St PltLlo WqM slualud of paptnold satotlod pue salm ualipm -q luawgstund luotsAid/Jujodioo ON •q uaJPligo agl3o Jana[ lEtluaP3uoa lda>[uaipinlo lnogE uotlEulio3ul t �Eluowdoianap pue aoE of oluudoiddE autldtosia •u LZ palsod uE asuodsa uu ssau omda� �3=5�aw s Id 21 P P d 3'3 (Of-6£saLEd)saatlaead rCaeugdtas!(j 'OI palsod saatlou uotlou asnnpe/anlloa»oZ) a S. uolaq IEuosiod Suuols io3 Pitllo gova iol ooudS •o Q 131ppol/luu3ut pro jol palsod uuo3 aotlou otlgnd p pal�tnoid Dunpolo pue siadutp tip`uualo luato nS q luojud 4q paptnold palsod lJodai iouatogap luaoa�lsolA o Pltgo goEa jo3 tUtglolO[EUOMIS ajLildo.lddV •E palsod uotlunJena tutauaotl luaoaJ lsoiN -q 1 ;` (G£atud) stuttuolag luuos tad •6 Z o Z Z o 1 o : n 0. -> o o D o 0 3 0' ° m m m i U U N U U REGULATIONS 0 RLGULATIONS M cu E o 0- E E 0- U Q o 0 U Q Z Z z o Z d. Physical/structural chances to home or ground 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 cri a. Record for licensee/household members(see O checklist) er of cribs that meet the US Consumer Product Safety Act of 2008: b. Records for caregiverlsubstitute(see checklist) c. Infants placed on back to sleep c. Records on caregivers/substitutes kept at least Iwo d. Each child 18 months 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 hild 5. Breakfast served to each child who goes leaves directly to school unless provided by school or parent g. Children's records and information about child i en 6. Evening meal provided for each child and their families kept confidential continuing from day time care h. Confidential information accessible only to H. Group Day Care Homes(pages 47- authorized persons 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 two1. 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 homes providing care after 7p.m. ;. Complete record for assistant caregiver 1. Number and age range of children does not ex feed 4. Outdoor play area fenced number and age range on license/permit 2. Bathing (page 46) 5. Required equipment provided(See checklist for ✓✓✓��� details) a. Clean water provided for each child I. Group Nighttime Homes(page 50) q 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 f exceed number and age range on license/permit f>�/ 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. SiQnatur/,eNof l hated staff / Date Emerzenev Preparedness and Response Plans Checklist I ( D ) indicates compliance observed by DHR Licensing Representative ( �) indicates not in compliance ( S ) indicates certified by staff in charge(use only for#plan updated yearly,written documentation must be on rile) ZM M r Ft t.� 1 '� V r°`j3. i The plan shall include procedures that will l e 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 viiolence Location and use of fire extinguishers Evacuations due to; #Documentation of the following quarterly drills; Hazardous materials �. Fire 9s' Spills Tornado Gas leaks Lockdown Bomb threats 9 Fire Relocation 7 Infectious disease emergencies Telephones for on-site and off-site use Loss of power,water,or heat I aye, Location of the first aid and emergency supply kits Other threatening situations 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 specif'wu'��(And/'44 Posted in a Conspicuous place Owl n � conditions I d `� Reunification with parents U Submitted to the Department ° Supplies needed for shelter in place procedullies / Copies provided to all parents/guardians Transportation disaster procedures �r Staff training/reassignment as appropriate #Plan updated yearly Contact with local emergency management officials I I i I I i I 8 I y Equipment Checklist Codes: Use the following code when c nzpleting the cohimns for each category. ( ® ) indicates compliance ob'seri ed (q ) indicates not in compliance ( X ) indicates not applicable j The licensee shall provide a variety of toyl,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 I censee 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 s all provide at least four(d)items from each category for each age group. 2< Equipment for Children 2%Z markers,paper,chalk,blunt-end 1. Equipment for Children scissors,paste,glue,playdough, t Years u to 6 Years paints(tempera or water color), Up to 2/z YearS � long handled brushes,finer aints A variety of age-appropriate books RA TIEMM.. accessible to the children Sand or digging area with items for A device that plays a variety of age- Small wheel toys digging,filling,sifting,and pouring Push and pull toys Climbing structure with soft appropriate music �� Boxes of assorted sizes surface underneath Rhythm instruments Swings with safety seat,infant swing Wheel toys I f Sand or di Qin area, toys for go Buckets for water play,items for a pouring,measuring,floating Collections of rocks,leaves,seeds, di ,ging, ourin,sifting etc. Large Balls Puzzles Aquarium with fish (must be I a + covered) Simple puzzles Beads or spools and string for Magnifying glass stringing Nesting and stacking toys �1 Peg boards and pegs —Ma nets 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 v Creative construction sets Years and Older Blocks 0 7Children all have a se arate area Small cars,trucks,boats,trains 0 pPaper ; heir personal items and Non-toxic crayons ir� ' Dolls,with clothes,blankets, Non-toxic water color markers 6 storage area Non-toxic play dough Doll stroller Non-toxic art materials:a variety of kinds of paper, scissors, glue, i+ Doll bed or cradle a crayons, markers, chalk, paints, Crib mobiles(for infants younger Dress-up clothes clay, la dou h than 5 months) Books and magazines appropriate Home living area-kitchen b Washable teething rings to the aces of the children appliances may be purchased or Rattle toys made from cardboard boxes A device that plays a variety of age- . P� Play dishes,plastic baby bottles, approprate music and stories Squeeze toys pots and pans,measuring spoons ► Soft cuddly toys Puppets Dress-up clothes Busy boxes Sheet or bedspread for making a Dolls and dolls clothes _ tent X Costumes and masks Dolls,and clothes and blankets Cardboard boxes in assorted sizes Mirror I + 1 N i � Dress-up clothes � Interlocking manipulative play sets Homeliving area-pretend kitchen Toy telephone Jigsaw puzzles appliances may be made from boxes , Toys,dishes,pans,spoons,plastic Dish pan Board games and playing cards O containers with lids Toy telephone Sponges Puppets Bubble mixture Balls Strainers Funnels n Bats Egg beaters Tether ball Small boats and other floating toys Croquet set " o Badminton set Non-toxic art materials-large Horseshoes pencils and crayons,water color Wheel toys �I I 11