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MARYLAND STATE DEPARTMENT OF EDUCATION - Office of Child Care Licensing

FAMILY CHILD CARE HOME INSPECTION REPORT

TIER____

ACCREDITED: Y N

ACCREDITED BY: __________________________________________ EXP DATE: ______/______/______Month Day Year

HOMEOWNERS INSURANCE COVERAGE: N/A Y N EXP DATE: _____/______/______Month Day Year

BUSINESS NAME: JURISDICTION: REGION:

PROVIDER NAME: REGISTRATION #:CO-PROVIDER NAME: INSPECTION DATE/TIME:

ADDRESS: PERSON(S) INTERVIEWED:

TELEPHONE: TITLE(S):

E-MAIL:

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.

INSPECTION TYPE

Initial/Resumption of Service

ConversionMandatory Review

Full

Complaint Investigation

Monitoring

Other

AGESRegistered

for# Enrolled # Present

ResidentChildren

0-23 Months

2s3s

4s

5s (pre-school)

5-12 (school-age)

TOTAL

Overnight XXXXXX

Head Start XXXXXXX XXXXXX XXXXXX

INSPECTION CODES

CD

NX

NA

--

---

In ComplianceDiscussed

Not in ComplianceNot InspectedNot Applicable

PART 1 - MANDATORY REVIEW ITEMS

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MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

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 CHAPTER 08 CHILD SUPERVISION

____.03B Continuing Registration ____.02 Off-Site Supervision

____.04B Conditional Status ____.04 Water Activity Supervision

____.05 Overnight Care SupervisionCHAPTER 03 MANAGEMENT & ADMINISTRATION

____.02 Admission to Care CHAPTER 09 PROGRAM REQUIREMENTS

____.03 Program Records ____.01 Activities

____.04 Child Records [exc. A] ____.02 Materials/Equipment

____.05 Notifications [exc. C-E] ____.03 Rest Periods

____.06 VariancesCHAPTER 10 SAFETY

CHAPTER 04 OPERATIONAL REQUIREMENTS ____.01 Emergency Safety

____.01 Hours of Care ____.03 Outdoor Safety

____.02 Age Group Enrollment ____.04 Water Safety

____.05 Transportation SafetyCHAPTER 05 HOME ENVIRONMENT & EQUIPMENT

____.01 Suitability of the Home CHAPTER 11 HEALTH

____.02 Lead-Safe Environment ____.01 Child Comfort/Welfare

.02 Exclusion for Acute Illness

PART 2 GENERAL COMPLIANCE REVIEW

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MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

BUSINESS NAME: JURISDICTION: REGION:

PROVIDER NAME: REGISTRATION #:

CO-PROVIDER NAME: INSPECTION DATE/TIME:

ADDRESS: PERSON(S) INTERVIEWED:

TELEPHONE: VISIT TYPE:

E-MAIL: 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.

_______________________________________________________ _______________________________________________________ ______________________Signature of Provider Signature of Agency Representative Date

REGULATIONNUMBER

REGULATION TEXT COMMENTS ADDITIONAL COMMENTSDATE

CORRECTED

STATEMENT OF FINDINGS PART 1

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MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

REGULATION(S) DISCUSSED:

Remarks:

Total number of regulations not in compliance: _____ Total number of regulations discussed: _____

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

Inspection results have been reviewed with me and will be: e-mailed to ____________________________________________________________________________

mailed

________________________________________________ _____________________________________________________ _____________________________

Signature of Provider Signature of Agency Representative Date

REGULATIONNUMBER

REGULATION TEXT COMMENTS ADDITIONAL COMMENTS

STATEMENT OF FINDINGS PART 2

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