7/31/2019 Letter of Compliance Inspection Form

1/5

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

LETTER OF COMPLIANCE INSPECTION REPORT

NURSERY SCHOOL: Y N TIER_____

ACCREDITED: Y N

ACCREDITING ORGANIZATION: ________________________________________ EXP. DATE: _______/_______/_______Mo. Day Year

WORKERS COMPENSATION INSURANCE COVERAGE: Y N EXP. DATE: _______/_______/_______Mo. Day Year

OPERATOR NAME: JURISDICTION: REGION:

FACILITY NAME: LETTER OF COMPLIANCE #:

ADDRESS: INSPECTION DATE/TIME:

PERSON(S) INTERVIEWED:

TELEPHONE:

E-MAIL: TITLE(S):

PART 1 - MANDATORY REVIEW ITEMS

INSTRUCTIONS: (1) Review each regulation that applies to the inspection being conducted.(2) Th li t t f it li t d d P t 2 b d d h d d

Approved Capacity:________

AGES

Approved

for # Enrolled # Present

2s

3s

4s

5s (pre-school)

5-15 (school-age)

TOTAL

Head Start XXXXXXX XXXXXX

INSPECTION TYPE

Initial Application

Conversion

Mandatory Review

Full

Complaint Investigation

Monitoring

Other

INSPECTION CODES

CDNX

NA

-----

In ComplianceDiscussedNot in ComplianceNot InspectedNot Applicable

7/31/2019 Letter of Compliance Inspection Form

2/5

(2) Th li t t f it li t d d P t 2 b d d h d d

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 APPLICATION AND MAINTENANCE CHAPTER 06 STAFF REQUIREMENTS

____.03C Continuing Letter of Compliance ____ .01 Minimum Staff Age

____.02 Staff OrientationCHAPTER 03 MANAGEMENT AND ADMINISTRATION

____.03 Suitability for Employment____.01 Multi-Site Facilities

____.04 Staff Health____.02 Admission to Care

____.05 Substitutes

____.03 Program Records____.06 Support Personnel

____.04 Child Records____.07 Volunteers

____.05 Staff Records

____.06 Notifications [exc. A] CHAPTER 07 CHILD PROTECTION

____.07 Change of Operation ____.01 Prohibition of Abuse, Neglect, Injurious Treatment

____.08 Variances ____.03 Child Discipline

____.04 Parental AccessCHAPTER 04 OPERATIONAL REQUIREMENTS

____.05 Authorized Release____.02 Enrollment and Attendance

CHAPTER 08 CHILD SUPERVISIONCHAPTER 05 PHYSICAL PLANT AND EQUIPMENT

____.01 Individualized Attention and Care [exc. A]

____.01 Building Safety [exc. A]____.02 Staff Available for Emergencies

____.02 Accessibility____.04 Variations in Group Size

03 Indoor Space

PART 2 GENERAL COMPLIANCE REVIEW

7/31/2019 Letter of Compliance Inspection Form

3/5

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 09 PROGRAM REQUIREMENTS CHAPTER 12 NUTRITION

____.01 Materials and Equipment ____.01 Food Service

____.02 Rest Furnishings ____.02 Modified Diet

____.03 Storage ____.03 Food Sources

____.04 Food Storage and Preparation [exc. A]

CHAPTER 10 SAFETY____.05 Food Preparation Area and Equipment

____.01 Emergency Safety Requirements [exc. A(4), C]

____.02 First Aid and CPR CHAPTER 13 ADOLESCENT FACILITIES

____.05 Transportation ____.01 Approved Plan

CHAPTER 11 HEALTH CHAPTER 14 EDUCATIONAL PROGRAM

____.01 Exclusion for Acute Illness ____.06 Personnel Qualifications

____.02 Infectious and Communicable Diseases ____.07 Educational Program

____.03 Preventing Spread of Disease ____.08 Child Records

____.04 Medication Administration and Storage ____.09 Health, Fire Safety, Zoning

____.05 Smoking

CHAPTER 15 INSPECTIONS, COMPLAINTS AND____.06 Alcohol and Drugs ENFORCEMENTS

PART 2 GENERAL COMPLIANCE REVIEW (continued)

7/31/2019 Letter of Compliance Inspection Form

4/5

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

PART I

OPERATOR NAME: JURISDICTION: REGION:

FACILITY NAME: LETTER OF COMPLIANCE #:

ADDRESS: INSPECTION DATE/TIME:

PERSON(S) INTERVIEWED:

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 the suspension or revocation of your letter of compliance.

_________

Signature of Facility Representative Signature of Agency Representative Date

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

4

REGULATIONNUMBER

REGULATION TEXT COMMENTS ADDITIONAL COMMENTSDATE

CORRECTED

STATEMENT OF FINDINGS PART 1

7/31/2019 Letter of Compliance Inspection Form

5/5

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 Facility Representative Signature of Agency Representative Date

5

REGULATIONNUMBER

REGULATION TEXT COMMENTS ADDITIONAL COMMENTS

STATEMENT OF FINDINGS PART 2