MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

LETTER OF COMPLIANCE INSPECTION REPORT

INSPECTION TYPE Initial Application 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 2s 3s 4s 5s (pre-school) 5-15 (school-age) TOTAL Head Start Approved Capacity:________
Approved for # Enrolled # Present

XXXXXXX

XXXXXX

NURSERY SCHOOL: ACCREDITED:

Y Y

N N

TIER_____

ACCREDITING ORGANIZATION: ________________________________________ WORKERS COMPENSATION INSURANCE COVERAGE: Y N

EXP. DATE: _______/_______/_______ Mo. Day Year EXP. DATE: _______/_______/_______ Mo. Day Year REGION:

OPERATOR NAME: FACILITY NAME: ADDRESS:

JURISDICTION: LETTER OF COMPLIANCE #: 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) 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.

____.03.06A ____.04.01B ____.05.01A ____.05.08A ____.05.11 ____.05.12 ____.07.02 ____.07.06

Notification of New Employee Capacity Building Safety Appropriate Facilities and Supplies General Cleanliness and Disposal of Refuse Outdoor Activity Area Abuse and Neglect Reporting Child Security

____.08.01A ____.08.03 ____.08.07 ____.10.01A(4) ____.10.01C ____.10.03 ____.10.04 ____.12.04A

Appropriate Supervision Group Size and Staffing Playground Supervision Emergency Escape Route Posted Emergency Contact Posted Safe Use of Materials and Equipment Potentially Hazardous Items Food 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 ____.03C

APPLICATION AND MAINTENANCE Continuing Letter of Compliance

CHAPTER 06 ____.01 ____.02

STAFF REQUIREMENTS Minimum Staff Age Staff Orientation Suitability for Employment Staff Health Substitutes Support Personnel Volunteers CHILD PROTECTION Prohibition of Abuse, Neglect, Injurious Treatment Child Discipline Parental Access Authorized Release

CHAPTER 03 ____.01 ____.02 ____.03 ____.04 ____.05 ____.06 ____.07 ____.08 CHAPTER 04 ____.02

MANAGEMENT AND ADMINISTRATION ____.03 Multi-Site Facilities ____.04 Admission to Care ____.05 Program Records ____.06 Child Records ____.07 Staff Records Notifications [exc. A] Change of Operation Variances OPERATIONAL REQUIREMENTS ____.05 Enrollment and Attendance CHAPTER 08 CHILD SUPERVISION Individualized Attention and Care [exc. A] Staff Available for Emergencies Variations in Group Size Supervision during Water Activities Supervision during Transportation CHAPTER 07 ____.01 ____.03 ____.04

CHAPTER 05 ____.01 ____.02 ____.03 ____.04 ____.05 ____.06 ____.07 ____.08 ____.09 ____.10 ____.13

PHYSICAL PLANT AND EQUIPMENT ____.01 Building Safety [exc. A] ____.02 Accessibility ____.04 Indoor Space ____.05 Building Repair and Maintenance ____.06 Lead-Safe Environment Ventilation and Temperature Water Supply Sanitary Facilities and Supplies [exc. A] Lighting Telephone and Communication Swimming Facilities

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing PART 2 GENERAL COMPLIANCE REVIEW (continued) INSTRUCTIONS: The compliance status of an item listed under Part 1 is excepted (exc.) from recording under Part 2.

CHAPTER 09 ____.01 ____.02 ____.03 CHAPTER 10 ____.01 ____.02 ____.05 CHAPTER 11 ____.01 ____.02 ____.03 ____.04 ____.05 ____.06

PROGRAM REQUIREMENTS Materials and Equipment Rest Furnishings Storage SAFETY

CHAPTER 12 ____.01 ____.02 ____.03 ____.04 ____.05

NUTRITION Food Service Modified Diet Food Sources Food Storage and Preparation [exc. A] Food Preparation Area and Equipment ADOLESCENT FACILITIES Approved Plan EDUCATIONAL PROGRAM Personnel Qualifications Educational Program Child Records Health, Fire Safety, Zoning

Emergency Safety Requirements [exc. A(4), C] First Aid and CPR Transportation HEALTH Exclusion for Acute Illness Infectious and Communicable Diseases Preventing Spread of Disease Medication Administration and Storage Smoking CHAPTER 15 Alcohol and Drugs ____.02 INSPECTIONS, COMPLAINTS AND ENFORCEMENTS Inspections CHAPTER 13 ____.01 CHAPTER 14 ____.06 ____.07 ____.08 ____.09

_____________________________________ Signature of Agency Representative

___________________________________ Signature of Facility Representative

__________________ Date

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

STATEMENT OF FINDINGS PART 1

PART I
OPERATOR NAME: FACILITY NAME: ADDRESS: JURISDICTION: LETTER OF COMPLIANCE #: INSPECTION DATE/TIME: PERSON(S) INTERVIEWED: TELEPHONE: E-MAIL: VISIT TYPE: DURATION: REGION:

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. REGULATION NUMBER DATE CORRECTED

REGULATION TEXT

COMMENTS

ADDITIONAL COMMENTS

___ ___ ___

Signature of Facility Representative

Signature of Agency Representative

Date

MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care Licensing

4

STATEMENT OF FINDINGS PART 2

REGULATION(S) DISCUSSED:
REGULATION NUMBER REGULATION TEXT COMMENTS ADDITIONAL COMMENTS

Remarks:

Total number of regulations not in compliance: _____ I request a review of findings N Y Review requested for the following regulation(s):

Total number of regulations discussed: _____

Inspection results have been reviewed with me and will be:

e-mailed to __________________________________________________________ mailed _____________________________________________________ Signature of Agency Representative 5 _______________________ Date

___________________________________________________ Signature of Facility Representative