MARYLAND STATE DEPARTMENT OF EDUCATION - Office of Child Care Licensing

FAMILY CHILD CARE HOME INSPECTION REPORT

INSPECTION TYPE Initial/Resumption of Service Conversion Mandatory Review Full Complaint Investigation Monitoring Other INSPECTION CODES C D N X NA In Compliance Discussed Not in Compliance Not Inspected Not Applicable AGES 0-23 Months 2s 3s 4s 5s (pre-school) 5-12 (school-age) TOTAL Overnight Head Start
Registered for # Enrolled # Present Resident Children

XXXXXXX

XXXXXX

XXXXXX XXXXXX

TIER____ ACCREDITED: Y N EXP DATE: ______/______/______ Month Day Year EXP DATE: _____/______/______ Month Day Year JURISDICTION: REGISTRATION #: INSPECTION DATE/TIME: PERSON(S) INTERVIEWED: TITLE(S): REGION:

ACCREDITED BY: __________________________________________ HOMEOWNERS INSURANCE COVERAGE: N/A Y N

BUSINESS NAME: PROVIDER NAME: CO-PROVIDER NAME: ADDRESS: TELEPHONE: E-MAIL:

PART 1 - MANDATORY REVIEW ITEMS

INSTRUCTIONS: (1) Review each regulation that applies to the inspection being conducted. (2) The compliance status of an item listed under Part 2 may be recorded when deemed necessary. (3) Initial/Resumption/Conversion/Full Inspection - Complete both Part 1 and Part 2.

____.02.01D ____.03.04A ____.03.05C-E ____.04.03 ____.05.03 ____.05.04 ____.05.05 ____.05.06

Certificate Conspicuously Displayed Emergency Forms Notification of Changes Child Capacity Cleanliness and Sanitation Rooms Used for Care Outdoor Activity Area Rest Furnishings

____.06.02 ____.07.01 ____.07.02 ____.07.04 ____.07.07 ____.08.01 ____.08.03 ____.10.02 ____.10.06

Training Requirements Prohibition of Abuse, Neglect, Injurious Treatment Abuse and Neglect Reporting Child Discipline Child Security General Child Supervision Supervision of Resting Children Potentially Hazardous Items Rest Time Safety

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

PART 2 GENERAL COMPLIANCE REVIEW

INSTRUCTIONS: The compliance status of an item listed under Part 1 is excepted (exc.) from recording under Part 2.
CHAPTER 02 REGISTRATION APPLICATION AND MAINTENANCE ____.03B Continuing Registration ____.04B Conditional Status CHAPTER 03 MANAGEMENT & ADMINISTRATION ____.02 ____.03 ____.04 ____.05 ____.06 Admission to Care Program Records Child Records [exc. A] Notifications [exc. C-E] Variances CHAPTER 10 SAFETY CHAPTER 04 OPERATIONAL REQUIREMENTS ____.01 ____.02 Hours of Care Age Group Enrollment ____.01 ____.03 ____.04 ____.05 CHAPTER 05 HOME ENVIRONMENT & EQUIPMENT ____.01 ____.02 Suitability of the Home Lead-Safe Environment CHAPTER 11 HEALTH ____.01 ____.02 CHAPTER 06 PROVIDER REQUIREMENTS ____.03 ____.03 ____.04 ____.05 Provider Substitute ____.04 Additional Adult ____.05 Volunteers ____.06 CHAPTER 07 CHILD PROTECTION CHAPTER 12 NUTRITION ____.03 ____.05 ____.06 Applicability to Residents ____.01 Parental Access ____.02 Authorized Release CHAPTER 13 INSPECTIONS, COMPLAINTS & ENFORCEMENTS ____.01 Inspections Food Storage/Cleanliness Nutrition/Food Served Consumption of Alcohol/Drugs Smoking Medication Administration/Storage Infectious/Communicable Diseases Child Comfort/Welfare Exclusion for Acute Illness Emergency Safety Outdoor Safety Water Safety Transportation Safety CHAPTER 09 PROGRAM REQUIREMENTS ____.01 ____.02 ____.03 Activities Materials/Equipment Rest Periods CHAPTER 08 CHILD SUPERVISION ____.02 ____.04 ____.05 Off-Site Supervision Water Activity Supervision Overnight Care Supervision

____________________________________________ Signature of Provider

_________________________________________ Signature of Agency Representative

___________________ Date

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

STATEMENT OF FINDINGS PART 1

BUSINESS NAME: PROVIDER NAME: CO-PROVIDER NAME: ADDRESS:

JURISDICTION: REGISTRATION #: INSPECTION DATE/TIME: PERSON(S) INTERVIEWED:

REGION:

TELEPHONE: E-MAIL:

VISIT TYPE: DURATION:

REGULATION(S) NOT IN COMPLIANCE:

NOTE: Failure to correct violation(s) listed below may result in sanctions being imposed or in the suspension or revocation of your registration.

REGULATION NUMBER

REGULATION TEXT

COMMENTS

ADDITIONAL COMMENTS

DATE CORRECTED

_______________________________________________________ Signature of Provider

_______________________________________________________ Signature of Agency Representative

______________________ Date

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

STATEMENT OF FINDINGS PART 2 REGULATION(S) DISCUSSED:

REGULATION NUMBER REGULATION TEXT COMMENTS ADDITIONAL COMMENTS

Remarks:

Total number of regulations not in compliance: _____

Total number of regulations discussed: _____

I request a review of findings. N Y Review requested for the following regulation(s): _________________________________________________________________________________________________

Inspection results have been reviewed with me and will be:

e-mailed to ____________________________________________________________________________ mailed _____________________________________________________ Signature of Agency Representative _____________________________ Date

________________________________________________ Signature of Provider