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` BILL NO. 2000-57 A
SPONSORED BY COUNCILMAN Vincent
;.x
ORDINANCE NO. i
AN ORDINANCE OF THE CITY OF JEFFERSON, MISSOURI, AUTHORIZING THE
„t MAYOR AND CITY CLERK TO EXECUTE AGREEMENTS WITH COLE COUNTY
HEALTH DEPARTMENT FOR PAYMENT OF CHILD CARE FACILITY INSPECTIONS.
d
BE IT ENACTED BY THE COUNCIL OF THE CITY OF JEFFERSON, MISSOURI, AS
FOLLOWS: r:a
Section 1. The Mayor and City Clerk are hereby authorized and directed to fir 4'
k;:s• y
execute agreements with Cole County Health Department for Payment of Child.Care
Facility Inspections.
Section 2. The agreements shall be substantially the same in form and content
as those agreements attached hereto as Exhibit A covering October 1, 1999 through
September 30,2000 and Exhibit B covering October 1, 2000 through September 30, 2001.
Section 3. This Ordinance shall be in full force and effect from and after the date
approval.
Passed:
of its passage and app F.
P Approved:
S�DU f
assed:
' Presiding O icer
APPROVED AS TO FORM:
ATTEST:
k' y Cler City Counsel or
N MEMO
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AGREEMENT
WHEREAS,Cole County Health Department intends to contract with the City of Jefferson(Subcontractor-SC) for the
41" perfortnturce Of Cer'til.in tasks;
�t WHEREAS,SC Is identified as follows:
Name: City of Jefferson
'Type of entity:
[ ] Sole proprietorship [ ] Professional corporation [ ] Individual
E [ ] Partnership [x] Corporation-municipal
Principal place of business: 320 East McCarty Street,Jefferson City,Missouri,65101.
lusiness telephone: (573) 634-6418
Employer ID number: 44-6000193•and
WHEREAS,SC declares that SC is engaged in the same or similar activities for other clients and that Cole County Health
Department is not SC's sole and only client or customer.
THEREFORE,INCONSIDERATION OF THE FOREGOING REPRESENTATIONS AND THE FOLLOWING TERMS
AND CONDITIONS,THE PARTIES AGREE:
1. SERVICES TO BE PERFORMED. SC is hereby engaged to perform Local Sanitation Inspections of child care
facilities within the City limits. See attached Scope of Work for details.
`
2. TERMS OF PAYMENT. Cole County Health Department shall pay SC according to the terms and conditions set
# forth in Section 4.0, Invoice/Reporting, of the attached Scope of Work. Cole County Health Department will retain eight . ;; £:
percent (8%) of accounts received for administrative costs. Any other covered expenses will require prior authorization
by Cole County Health Department.
x PAYROLL OR EMPLOYMENT TAXES. Neither federal,nor state,nor local income tax,nor payroll tax of any
kind shall be withheld or aid b Cole Count Health Department on behalf of SC or the employees of SC.
l: P Y Y P :v�4 '��n> �•
4. WORKERS'COMPENSATION. No workers'compensation insurance shall be obtained by Cole County Health
Department concerning SC or SC's employees. SC shall comply with the workers'compensation laws with respect to SC
'
and SC's employees.
` 5. TERMINATION. This agreement may be terminated with thirty(30)days prior written notice from one party to
'J
the other.
6. Contract shall be for period from October i,2000 through September 80,2001. c �' p�d 'O ✓ ;,,t;^.2 ,'`til;
Agreed to this r day of o T�{� ,20(10 at Jefferson City, State of Missouri. "y;
, , ,
COLE COUNTY HEALTH DEPARTMENT CITY OF JEF ERSON MIS I p
Title: �;� /� 'a N yor
�7RL a:'
nty Auditor City' erk
APPR +D AST
y CouC 11selor-
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Local Sanitation Inspections for Child Care Facilities
' SCOPE OF WORK ' :
October 1, 2000 through,September 30, 2001 x rJrr;4+Y4.
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1.0 PURPOSE
1.1 To localize sanitation inspections in all types of child care facilities(Exhibit A) regulated by
_. the Missouri Department of Health. Localization will result in a higher quality, more timelyq!'
and consistent inspection, consequently providing a safer, healthier environment for children
in care.
2.0 DELIVERABLES
The Contractor Shall:
2.1 Provide sanitation inspections relating to disease prevention, safe food handling, safe
storage of toxic agents, cleaners and medicines, pes t control, safe water su plies, safe on-
P '�',�.�"•�t
site sewage disposal, and basic evaluation of lead hazards and other environmental hazards
in all regulated child care facilities.
' 2.2 Conduct Initial Sanitation Inspections in child care facilities.
2.2.1 Upon receipt of the provider application, the Depart ment s Bureau of Child Care (BCC) ,.,e<y ' .. ,•
:T District/Area office will forward a Request for Child Care Inspection, DC-33(Exhibit B) J.
to the Contractor. The following inspection forms, dependent on the type of facility, "��tfrµu
Yt( j. C4i.•L.
shall be used to document the results of the inspect ion:
to.i w� f' }I'''✓
a Sanitation Inspection Re ort/Family Child Care Home, DC-34 (Exhibit C)
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b) Sanitation Inspection Report/Licensed Centers Group Homes and License-
y Exempt Facilities, DC-35 (Exhibit D)
Sanitation Inspection Reporf/Summer School Age Program. DG 112(Exhibit
# sgrw
s E
.;: Sanitation Inspection Reports, (DC-34, DC-35 and DC-112)will be provided to
! , the Contractor upon request to the BCC District Office. "'S , -",'
2.2.2 The Contractor shall contact the provider within 10 working days of receipt of the
Request for Child Care Inspection to establish a mutually agreeable time for the initial
q p1:<.
inspection. The inspection shall take place within 20 working days after the initial
` contact with the provider or as agreed upon by the Contractor and provider.
5a�n '
The completed initial Sanitation Inspection Report(DC-34, 17C-35 or DC-112)an the
Request for Inspection (DC-33) shall be received by the BCC Central Office within 10 .J rb•..q,
. working days of the inspection.
2.3 Conduct Annual Sanitation Inspections for existing child care facilities.
r
' 2.3.1 A Request for Child Care Inspection(DC-33) shall be sent to the Contractor by BCC ;
't District/Area Office at least 60 days prior to the inspection due date. One of the snr,
followin inspection forms, dependent on the type of facility, shall be used to
.a g spit' pe ;,.�
document the results of the inspection:
u
a) Sanitation Inspection Report/Family Child Care Home. DC-34(Exhibit C) 's"
b) Sanitation Inspection Report/Licensed Centers Groun Homes and License-
Exempt Facilities, DC-35 (Exhibit D)
c) Sanitation Inspection Report/Summer School Ace Program, DC-112(Exhibit
E) ;
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2.3.2 The annual inspection shall occur at least 30 days prior to the due date as indicated on
t the DC-33. The appropriate, completed Sanitation Inspection Report (DC-34, DC-35
or DC-112) shall be received by the BCC Central Office within 10 working days of the
l .
Y ' inspection, The annual inspection and the reinspection must be completed by the due
date as indicated on the DC-33.
2.4 Conduct Reinspections for those facilities not approved as a result of the initial or annual
�
inspections.
1nS
2.4.1 For initial inspections, if a reinspection is necessary, it shall occur within 20 working
Y
days after the initial inspection, or as agreed upon by the Contractor and provider. The
days
reinspection report also submitted on a DC-34, DC-35 or DC-112)shall be submitted }£J .yp,
t; p p°
with a copy of the DC-33 and received by the BCC within 10 working days of the
reinspection. Additional inspections, classified as special circumstances,shall require
verbal and written approval from the BCC District Environmental Public Health
Specialist(DEPHS). See Sect ion 2.5.1.
a i.0 yi�ri?rl� r.
2.4.2 For annual inspections, if a reinspection is necessary, it shall occur b the ins ion
DC-
due date as indicated an the DC-33. The reinspection report(also submitted on a DC.-
34, QC-35 or DC-112)shall be submitted.with a copy of the DC-33 and received by the
BCC within 10 working days of the reinspection. Additional inspections, classified as
special circumstances, shall require verbal and written approval from the BCC
DEPHS. See Section 2.5.1.
:.v 2.5 Conduct Special Circumstance Sanitation Inspections arising from unique circumstancesj .},k
xr �xs
such as emergency situations, disease outbreaks, exposure to environmental hazards, 4 �
reports of rule violations(complaints), or continued noncompliance after reinspection.
2.5.1 Special circumstances requiring additional inspections(beyond the initial, annual
a rt• a�
and/or one reinspection)shall be initiated through a verbal or written request by the �C;;�.
dx
.';
BCC or the Contractor and be based on the availability of the Contractor. The special4 ,., }, k,4 L.
circumstance inspection report(also submitted on a DC-34, DC-35 or DC-112) shall be
s it�,rt r
received by the BCC within 10 working days of the inspection. Written approval (DC-
33) is required in order to be reimbursed for a special circumstance inspection. 's ?�r, .
2.6 Conduct Lead Risk Assessments for those facilities where a lead hazard has been lf ' ,ti`
}t,�tl(,;4 sit r,�,•:':«<'
" ! 2.6.1 Lead risk assessments shall only be conducted by a licensed lead risk assessor.
` 2.6.2 Lead risk assessments shall be initiated by the BCC and be based on the availability of
the Contractor. Verbal or written approval (DC-33) is required from the BCC DEPHS
a in order to conduct a lead risk assessment. Written approval (DC-33) is required in
order to be reimbursed for a lead risk assessment. {'; •,r
2.6.3 A lead risk assessment may also be initiated by the Contractor. Verbal or written rti �,;4
approval (DC-33) is required from the BCC DEPHS in order to conduct a lead risk �•,>, : .,•+ i
7, assessment. Written approval (DC-33) is required in order to be reimbursed for a lead
•`a� �' �'r�•.:;fit"
risk assessment. ;{
2.6.4 A lead risk assessment report shall be received by the BCC within the agreed upon } ,
;+t..
timeframe. The BCC EPHS and local inspector will determine the time frame when - ;fkr Q
r the lead risk assessment is initially requested. A copy of the DC
and all required '
t:
DC-34, DC-3 5 or DG112,with all identifying information at the top of the form
r completed, must be attached to the lead risk assessment report.
2.7 Required Child Care Sanitation Inspector QualificationslTraining
r' The Contractor shall assure their inspectors successfully complete the following: t
`r 7/17100
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2.7.1 Sanitation Inspector Qualifications
Child Care Sanitation Inspectors shall qualify at the level of Environmental Public r } •;` j``Y
.;:
.
Health Specialist I or above and have at least six months of work experience in the
field of environmental health.
RRJ 4 ,Vt•_.
2.7.2 Initial Required Training
0i, initial required training shall be completed prior to approval of inspection
reimbursemen t
It 3.0 Monitoring/Training
'a 3.1 BCC DEPHS will provide annual classroom instruction for all participating Inspectors.
Pa 9 l� •i' ��r 4
rr f
Classes will be conducted in each of the respective district locations and shall be conducted
each contract period. Other sessions on new information and resources will be conducted as
needed.
3.2 The Child Care Sanitation Inspection Manual and its revisions, shall be distributed to each
` local city/county health office participating in the contract.
1 5; LKG`�ttlY( ' t
3.3 Training will be provided by the BCC in the process for handling variance requests from
providers.
3.4 Quarterly Child Care Inspector training s will be conducted as needed to address training for �� r t
"x new or additional employees wishing to provide child care sanitation inspections. =, km '
3.5 Field Training/Monitoring
��,
t;.
3.5.1 The BCC DEPHS's will accompany each previously contracted local Inspector on a
least four field monitoring inspections to include at least one family home using thea,i ;.
Form (DC-110) (Exhibit F). All four of these facilities ' y:s
Field Monitoring Summary
should involve infantAoddler care.
3.5.1.1 The Contractor shall contact the BCC DEPHS's and schedule these field . �r?'
monitoring inspections. A minimum of one field monitoring inspection shall
:.
be completed per quarter unless all four field monitoring inspections have
completed earlier. ,`'"
been comp : '•,;;��
pany each newly contracted and/or new local Inspector
3.5.2 The BCC DEPHS's will accomIis `'
s of inspections:
''•' on the following type p�� '•
,tynit•'..
ta« 1) two field monitoring inspections in centers and/or group homes involving
infanVtoddler care;
2) two family homes involving infant/toddler care; it
r
, �M1Lrha!-
3) one nursery school; and
:3,tiWi tr' .tk� k,
l,i G0.S J
4) one religious organization involving infant/toddler care. fiur,,k.
_.:
yx, 3.5.2.1 The Contractor shall contact the BCC DEPHS's and schedule these field rf
�y•j" 1
`}t r
monitoring inspections. A minimum of one field monitoring inspection shall
?=,
t be completed per quarter unless all six field monitoring inspections have '
4 ;
been completed earlier.
6� fi
3.5.3 The BCC DEPHS will conduct periodic desk monitoring of sanitation inspection 4••
t, reports submitted by each contractor using the Desk Monitoring Summary Form
(DC-111) (Exhibit G). Five randomly selected inspections from each inspector will
;.
be reviewed for timeliness,form completion, clear and concise documentation, r'
proper use of coding and for adherence to BCC policies and procedures. ';
tJC%,
3.6 Technical Assistance
7117/00 3 "'j. i
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3.6.1 All technical assistance relating to inspection issues shall be directed to the BCC ,��rx.,�r,;���.D•.1
DEPHS in their respective district offices(Exhibit H).
4.0 INVOICING/REPORTING
tnMn4�� �
4.1 The Contractor shall request reimbursement for services provided based on the following
payment schedule and shall bill using the Reimbursement Request for Child Care Sanitation ;ty, r�tyr,
Inspection form (DC-38-1 and DC-3 8-2)(Exhibit I). (4�t{ +u4:L'
;r... 4.2 Reimbursement Rates
Reimbursement rates for annual and reinspections shall be based on the established timet;i`'A,;�=t
frames in Section 2.0. Annual and reins ions conducted on or prior to the due date shall
be reimbursed for the full amount stated in Section 4.2,1 and 4.2.2. iii r tii
The Contractor shall be reimbursed at a rate not to exceed the following:
4.2.1 $80.00 per initial/annual inspection shall be reimbursed to Contractor. This rate
` includes reimbursement for mileage and travel time to and from the facility, inspection
equipment file review, inspection time form completion, administrative time and
I� technical assistance to providers. "
�4.sSki''lrye'{it;
4.2.2 $45.00 per reinspec:tion shall be reimbursed to Contractor. This rate includes
reimbursement for mileage and travel time to and from the facility, inspection
equipment, file review, inspection time, form completion, administrative time, and
technical assistance to providers.
4.2.3 $30.00 per hour shall be reimbursed to Contractor for services identified to be those
special circumstances requiring additional inspections. This rate includes ' ??;
reimbursement for mileage and travel time to and from the facility, inspection
equipment, file review, inspection time, form completion, administrative time, and
technical assistance to providers. (Requires prior approval from DEPHS.) ;�'af
4.2.4 $25.00 shall be reimbursed to Contractor when the BCC requests an inspection and fn` 5
upon arrival at the facility, it is found to be no longer in operation.
},�t
4.2.5 $45.00 per hour for lead risk assessments shall be reimbursed to Contractor. This
u'+ rate includes reimbursement for mileage and travel time to and from the facility, Y i la
- equipment, file review, inspection time, form com p letion, administrative time, and
technical assistance to providers. `;"
��`' 7y'hs` tit•:.
NOTE: The quoted reimbursement rates shall apply to all types of facilities identified within
this contract. The Department reserves the right to reallocate funds based on the
Contractor's performance in achieving the goals and objectives set forth in this .t:r;,;
Pe g .n.
contract.
4.3 Reimbursement/Procedures '
r; 4.3.1 A Reimbursement Request for Child Care Sanitation Inspections must be completed f rfc
Y' on a monthly basis and submitted to:
�iJ A1•
Bureau of Child Care �: r
Missouri Department of Health
P.O. Box 570, 912 Wildwood r V.
Jefferson City, MO 65102
.r
Invoices shall be submitted by the last day of the month following the month of the f:,i
inspection, (i.e., if the inspection is completed in May,the Reimbursement Request ;r '
g (DC-38)for the billing month of May must be submitted no later than June 30.)
7/17/00 4
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>?
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} x.Ur,
q TO,
�(t
uired deadline will be ineligible for payment. incomplete
Invoices received after the req
invoices shall be returned to the Contractor for completion which will delay the ;: 1,rj'rt
reimbursement process. Final invoices shall be submitted prior to October 31, 2001.
t ,,�x The Contractor shall submit to the Department uniquely identifiable invoices for a�i=,..;A1��,,;Y;: .
r' a:,:r
payment processing. Uniquely Identifiable means the particular invoice or bill can be
distinguished by invoice number from a previously submitted invoice or bill.
fR�} iP ty..x
i
4.3.2 All Sanitation Inspection Reports(DC-34's, DC-35's and DC-112's) shall be submitted
within 10 working days of the actual inspection. These reports will be collected in BCC twrk ;l
central office and matched to the Reimbursement Request for Child Care Sanitation
' Inspections forms(DC-38) at the end of each month. The Contractor shall assure that u ¢h11nPi� #
all Sanitation Inspection Reports(DC-34's, DC-35's and DC-112 s have been 1
submitted prior to sending the monthly Reimbursement Request for Child Care
(DC-38). ,x4'' >:
Sanitation Inspections
aid for work done prior to completion of the initial required
4.3.3 No reimbursement shall be p
sanitation training.
child care sa
4.3.4 No reimbursement shall be paid when inspection timeframes(as stated in 2.0
Deliverables of this Contract) are not met.
4.3.5 All billing/invoicing inquiries shall be directed to the BCC Central Office in
tfi{,}3 rtr
x Jefferson City, Phone Number, 5731751-2450.
4.3.6 Refunds. It is mutually agreed by both parties that if the contractor was overpaid br:
the Department, the contractor will issue a check made payable to"DOH-DOA- ee q
k. Receipts"within 10 days of official notification by the Department and shall mail the 4i.�;:,Y
� k,.taS.•:.
{- payment to: 'tY
1• ,;�`pa"
yS;j,'
Missouri Department of Health
Division of Administration
Fee Receipts y,
P.O. Box 570 ns
920 Wildwood Driver
Jefferson City, MO 65102-0570
5.0 SPECIAL PROVISIONS
�trl •.
n Inspection Manual
5.1 Child Care Sanitatio
bh c!.
5.1.1 This manual is a basic guide to the Missouri Department of Health, Bureau of Child
are's 1�' �,,�
*s inspection program regarding sanitation inspections conducted in child care facilities.
.ltrj. '�„Yrfrfv�if
The Contractor shall a and requirements contained in
ll dhere to all policies, procedures tk this manual and all its revisions. t'
' reimbursement of monthly
latin to the submission of invoices for
General instructions re 9
{; ion Manual. Assistance for invoicing
=a' billings are included in the Child Care Sanitation Inspect
"t t available
through the Department's Bureau of Child Care Central Office atr' ,
questions will be ava
573!751-2450, or through the DOH Groupwise communication system.
5.2 Variance Procedures
{� 5.2.1 State statute 210.252, 3. states"Any child care facility may request a variance from a
k"t
:. rule or regulation promulgated pursuant to this section. The request for a variance shall
, V
be made in writing to the Department and shall include the reasons the facility is
�i Department shall approve any variance request that does ; wv;
requesting the variance. The Depa ltiw`g
.t .t ;
not endanger the health or safety of the children served by the facility. The burden o
proof at any appeal of a disapproval of a variance application shall be with the
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approval b the
Department. Local inspectors may grant a variance, subject to app Y
,, :ra:
Department." ` ` +
and requirements regarding°
policies, procedures, ,
The Contractor shall adhere to all licies, p „ +h
?A,a 1stt,
variances as stated in Chapter V of the Child Care Sanitation Inspection Manual r4�
;.` z 'r�1tF ;
Contractors shall submit a written recommend rt,ve documentat on from 'which they based
their respective facilities, along with any suppo Exhibit J will be sent to the ,.�� ;,;•,
. � a
their decision. The variance form,Variance Request (DC-25)
BCC DEPHS for review. Variance forms shall be available through the district BCC office.
v'
6,3 Multiple County Contracts
Sr; t
5.3.1 !n those instances when the Contractor wishes to provide child care sanitation x�
inspections outside their immediate designated city/county, a letter of agreement Jq
all articipatin administrators, shallrir» i
between the respective agencies, signed by P g
ed and
accompany this signed contract and be returned to the Department. Documentation
should include a listing of all entities for which reimbursement is expected
s:,r•i{a u .
indicating the lead agency
to which reimbursement is to be made.
`-/ 5.4 Sanitation Training to Providers
for sanitation training to child care providers
5.4.1 The BCC will not reimburse inspectors
}>; training for providers can be coordinated and billed y ;
through this contract, however, �• �t, „'
Child Care
through the Department's Bureau of Nutrition and Child Care Programs,
sanitation training must be coordinated
Health and Safety Consultation contract. Any
with the appropriate local or district Child Care Nurse Consultant and BCC District
Environmental Public Health Spec' ,.
K` 5.5 The Department's Bureau of Child Care will provide all forms(Exhibits A-J) required for this
.';
%i4F I '
contract. +•r `t::
5.6 The BCC reserves the right to contact child care providers periodically to monitor quality
assurance. The BCC also reserves the right ehcontract
nduct offers may be'based on qualitynsecuice
areas to monitor quality assurance. Future ;fit,,
f , irk•:::,
{ history. rt ti: w,
a
policies, procedures, protocols, g
uidelines, reporting forms, and other related '�,t
5.7 All referenced po . Pu
Y'..
materials shall be included her
as fully set out• , .,..: Y.
',slr• ,i:4`,
,,yt fey 1
, 4h� 55••
S. lj�
s
7/17100 rn�
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EXHIBIT B 9 ,"V
k�r State of Missouri
Department of Health Page I of i '
<'
Bwghau of Child Care Safety & Licensure
t for Child Care Inspection
Zequest Date: 02/01/2000 l ; Y
:ocal Health Office: Child Care District Office: "ts 4
St . Louis City Dept . of Health Eastern District Health Office '
i 634 North Grand Child Care Unit
PO Box 14702 220 South Jefferson
St . Louis MO 63103 Second Floor
a;
St . Louis MO 63103 ' :.`+
JOHN SMITH
Phone: (314) 877-0210 . �• �;��,? "`
} 'acility## . 000783004 ;y+ ?
.DAVES KLEAN KIDS 'Yz '
'ontact : Inspection Due Date: 04/30/2000 ` ' `
3 STEP SANITIZE LANE Phone: (314) 533-7958 `L
SOAPY MO 63115 County: HEALTHY COUNTYf 'Y
The following information must be completed for initial sanitation inspections
'ATER SYSTEM Community Non-community Domestic
rr; EWAGE SYSTEM Community On-site r �k
Lagoon
_ Absorption Field
` Other 'l
i ions to Facility:
•ltr, x�t,t�r;�����,rc� '�•
s �rpe of Facility: Licensed Facility Family Child Care Home '
nitial License/Approval : 06/13/1996 Begin: 06/15/1998 End: 05/31/2000
ge Range : 00 YEARS - 14 YEARS 0 (under 2) 0 (over 2) Capacity: 10 f
-lifts
i.mi tations:
UNDER 2 ; DAYTIME CARE AND NIGHTTIME CARE
eason for Inspection: Annual fir:
., zange in : Capacity _ Age Range Building/Heating System _
:)mments
� J
' :STRIBUTION:White Canary- Inspector, Pink- CC Fac Spec, Goldenrod- BCCSL EPHS ,
i
-33 (HDCRP032) 8/18/1997 '
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EXHIBIT C Armial Time CODES
Page I of 2 a.m. X = Detects Noted
m.
` N.O. = Not Observed
MISSOURI DEPARTMENT OF HEALTH pepanure Time a m N.A. = Not Applicable
m
= Discussed and Agrees to
;. BUREAU OF CHILD CARE amply with requirements
SANITATION INSPECTION REPORT DATE
FAMILY CHILD CARE HOME
DVN COUNTY CODE
Dec NAME INSPECTOR'S NAME(Print) '
ADDRESS(Street.City.State.Zip Code)
An inspection of the premises of your facy has been made on the above date. Any detects are marked below with an X.
• • 1 - - • •
Premises clean and Tree of unsanitary conditions. 1. Food from approved source and in sound condition;no excessively
' 1• dented cans.
2. Premises free of environmental hazards. 2. No use of hume canned Iood. No unpasteurized milk.
( 3. No evidence of insects,spiders, rodents or pest harborage.
4. Well ventilated. no evidence of mold.noxious or harmful odors. 3. 11
store and prepare food lsafely with lahminimum of a stove or other
5. Screens on windows and doors used for ventilation to good repair. cooking equipment sized to meet the needs of the facility; a two
ion of lead hazards. with hot and cold running water; and a
6. No indicat compartment sink
7. No toxic or dangerous plants accessible to children. refrigerator poultry to 165° F; pork to 150° F;
4. c
• 8. Medicines and other toxic agents not accessible to children and Ground beef ooked to 155° F;p
and all other foods cooked to at least 140° F. All hot food kept at
stored to prevent contamination of child contact items. 140°F or above.
9. All sinks equipped with mixing faucets or combination faucets with 5 Precooked food reheated to 165°.
hot and cold running water under pressure.
access to children- 100°• 120° 6. Food requiring refrigeration stored at 41' F or below.
t sinks acc w accessible readable thermometer
urea or belo ,
rat F
Hot water temperature Refrigerator 41°
10. 7. Ret g
F. Temp at time of Inspection required. Foods in freezer frozen solid.
it. Pets free of disease communicable to man.
Pets living quarters clean.and well maintained. 8. Metal stemmed thermometer reading 0- 220° Fin 2° increments
12 for checking food temperatures.
9. Food, food related items and utensils covered and stored to
13. Reptiles are prohibited on the premises.Birds of the Parrot Family prevent contamination by pests, toxic agents, cleaning agents,
fed for Psittacosis.
water drain lines,medicines,dust,s lash and other foods.
1 mming/wading pools filtered,treated,tested and water quality 10. Food,toxic agents,cleaning agents not in their original containers
zt. .cords maintained.Meets local codes. shall b a properlp labeled.
11. No food stored or prepared in diapering area or bathrooms.
COMMUNITY
NON-COMMUNITY PRIVATE 12 Food stored in food grade containers only.
HIGH HAZARD CROSS CONNECTIONS 13. Food thawed under refrigeration, 70° F running water or
PRIVATES microwave it part of the cooking process.
Constructed 10 prevent contamination. 14. No animals in food preparation or food storage areas.
;i 15. No eating,smoking,drinking during food preparation.
Meets MDON-BCC requiremenWinneets local requirements
A. Bacteriological sample results. 16. Food served and not eaten shall not be re-served to children in
"'i B. Chemical(Prior BCC Approval Needed) care.
ON-SITE 1. Food utensils washed,rinsed and air dried.
COMMUNITY
DNR Regulated System-Type: 2. Single service items used only once.
OOH Regulated System-Type: 3. Food contact surfaces
cleaned in place are washed, rinsed, and
y O
1. Functioning properly at time of inspection.(circle) Yes No sanitized after each use with approved agents.
2. Single Family residence lot consisting (circle) Yes No 4, Infant/toddler toys washed, rinsed and air dried after contact with
at least daily.
of three acres or more. (circle) Yes No
body fluids,when soiled or
3, Health hazard to children. S. Diapering surface and potty chairs washed, rinsed and sanitized
:} after each use with approved age
Meets MDOH-BCC requirements meets local requirements
•
6. Test kits available to check proper concentration of sanitizing
1. Care givers and children wash hands using soap, warm running
agents.
water and sanitary hand drying methods. 7. Soiled laundry stored and handled in s manner which does not
d children wash hands after toileting, diapering, contaminate food and food related items and child contact items.
2. Care givers an • • ,
fisting with toil and nose blowing; before preparing food; ,•,. ,
handling raw food, cleaning and sanitizing, outdoor play, 1 Adequate number of containers.
trig animals,smoking and as necessary. 2• Clean,nonabsorbent.insect and rodent proof.
sink available in kitchen to wash hands during food 3. Outside refuse containers covered at all times.
3, t empty 4. Inside containers covered when lull or accessible to children.
preparation.
5. Soiled diapers stored in solid, non absorbent container with tight ; ,
4, Hand sink with warm bathroom and diapering.Ible at all times to wash Titling lid located in the diapering area.
g water hands after using
food tree Of infection or illness. PINrC/PROVIDER
' S, Personnel preparing R CAMARYANSPECTOFi H
DtSTR10UT1ON: wN(TE/BUREAU Of CHILD CA E
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Page I of3 EXHIBIT D AmvalTime
CODES
MISSOURI DEPARTMENT OF HEALTH a.m.
m. x = Detects Noted
BUREAU OF CHILD CARE Departure Time N.O. = Not Observed
HEALTH/SANITATION INSPECTION REPORT am. N.A. = Not a
Discuussed ssed a n
m nd Agrees to
LICENSED CENTERS, GROUP HOMES DATE comply with requirements
AND LICENSE-EXEMPT FACILITIES
❑ Initial ❑ Annual ❑ Reinspection ❑ Lead ❑ Special Circumstances - -
DVN COUNTY CODE
NAME
INSPECTOR'S NAME(Pnnl)
ADDRESS(SIt"I.Ct1y.Stale.ZIP Cate) `
An inspection of the premises of your facility has been made on the above date. Any defects are marked below with an X.
U.Tel i zffmm
1. Premises clean and free of unsanitary conditions. 1. Food from approved source and in sound condition;no excessively
2. Premises free of environmental hazards. dented cans.
3. No evidence of insects,spiders,rodents or pest harborage. 2. No use of home canned loud. No unpasteurized milk.
4. Well ventilated, no evidence of mold,noxious or harmful odors. 3. Ground beef cooked to 155° F; poultry l0 165° F;pork l0 150° F;
and all other foods cooked to at least 140° F. All hot food kept at
5. Screens on windows and doors used for ventilation in good repair. 140 1 For above,
6. No indication of lead hazards. 4. Precooked food reheated to 1651.
7. No toxic or dangerous plants accessible to children. 5• Food requiring refrigeration stored at 41°F or below.
8. Medicines and other toxic agents not accessible to children and 6- Refrigerator 41* F or below, accessible readable thermometer
stored to prevent contamination of child contact items. required. Foods in freezer frozen solid.
9. All sinks equipped with mixing faucets or combination faucets with 7• Metal stemmed thermometer reading 0-220°F in 21 increments for
I hot and cold running water under pressure. checking food temperatures.
` 10. Hot water temperature at sinks accessible to children-100°- 120°F. a, Food,food related items and utensils covered and stored to prevent
f Temp at lime of Inspection contamination by pests, toxic agents,cleaning agents,water drain
11 is free of disease communicable to man. lines, medicines,dust, splash and other foods.
! 1 living quarters clean,and well maintained. 9. Food, toxic agents, cleaning agents not in their original containers
shall be properly labeled.
1epliles are prohibited on the premises.Birds of the Parrot Family 10 No food stored pr prepared in diapering area or bathrooms.
tested for Psittacosis.
`. 1'I. Food stored in food grade containers only.
14. Swimming/wading pools filtered,treated,tested and water quality 12- Food thawed under refrigeration,70°F running water or microwave
records maintained.Meets local codes. if part of the cooking process.
LTM 13. No animals in food preparation or food storage areas.
r COMMUNITY - NON-COMMUNITY PRIVATE 14. No eating, smoking,drinking during food preparation.
HIGH UNITY HAZARD CROSS CONNECTIONS 15. Food served and not eaten shall not be reserved to children in
F?RIVATF�S, SO 4 - - , ;; :t,►t+<"r - care.
e
1. Constructed to prevent contamination. I '`
2. Meets MDOH-BCC requirements/meets local requirements 1. All food equipment, utensils and food contact surfaces washed,
A. Bacteriological sample results. rinsed and sanitized with approved agents, concentrations, and
B. Chemical(Prior BCC Approval Needed)
methods.
All utensils and toys air dried.
a COMMUNITY ON-SITE 3. The following items washed,rinsed and sanitized after each use:
A.Food utensils
DNR Regulated System-Type:
B.Food contact surfaces including eating surfaces,high chairs,etc.
DOH Regulated System-Type:
C.potty chairs
1. Functioning properly at time of inspection.(circle) Yes No
2. Single Family residence lot consisting (circle) Yes No D.Diapering surface
of three acres or more. E.InfanVToddler toys that have had contact with body fluids.
3. Health hazard to children. (circle) Yes No 4 The following items are washed,rinsed and sanitized at least daily:
A.Toilets. urinals,hand sinks.
F Meets MDOH-BCC requlrementslmeets local requirements B.Non-absorbent Iloors in infanl/toddler spaces.
'D HYGIENE
�.
C.Infanbtoddler toys used during the day.
1, a givers and children wash hands using soap, warm running
and sanitary hand drying methods. 5. Carpets spot cleaned and sanitized when contacted by body -,
:y fluids.
givers and children wash hands after toileting, diapering, ,
listing with toileting and nose blowing; before preparing food; 6. Test kits available to check proper concentration of sanitizing
';. agents.
after handling raw food. cleaning and sanitizing, outdoor play.
handling animals,smoking and as necessary.
7. Soiled laundry stored and handled in a manner which does not
y contaminate food and food related items and child contact items.
3. Personnel prepanng food free of infection or illness.
DISTRIBUTION: WHrreDUREALIOF CHILD CARE CANAFTYANSPECTOR PINK/PriOVIOER
DC•95-t
0 5f1o•1916(9.991
tx n'4`'•,"� t`.
:�� ,. u-�r�gyNY r Y't:.'�k'$""r^.a�ifl¢�'.'.tY:17iti"11'+,+h+9,1"'�1fTQ'ir.+3`�!;'��1,`S'�2 iRiL.t;,�a^rn1:•�r;4'.,.:wl�.is;.}�`�i4.i;f.,.4.,...P.�1in•.r,.r�3t'3,?,F.i!'�'1.=ih'rhdriFS,.�.t�f:�l;rtrf.'1� �t'f tl�tf�5,��iwt+ti9
' tom !� 7.. •'a
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� \ 9
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uw-
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Page 2 of 3
a'
VsTe-lel BAT • •
1. Single service Items not reused. 1. Cleaned as needed or at least daily,
II food equipment and utensils in good repair 2.All required equipment and dispensing fixtures in good repair.
d preparation and storage areas have adequate lighting. 3. Facilities approved after October 31, 1991, have bathrooms
Kitchen equipment that produces excessive grease laden vapors, enclosed with full walls and solid doors;doors closed when not in
moisture or heat properly vented. use
5. Facilities shall have mechanical refrigeration for facility use only. 4. Facilities approved after October 31, 1998 mechanically ventilated
Exception:License-Exempt facilities approved prior to October,31,1997 to prevent molds and odors.
i.
6. No carpeting or absorbent floor coverings in food preparation area. S. Hand washing sinks located in or immediately adjacent to the ,t�!;'>'',
7. Adequate preparation and storage equipment for hot foods. bathroom.
B. Facilities with a capacity of 20 children or less shall have: 6. No carpets on Iloors.
7. Sufficient lighting for cleaning.
A. Mechanical dishwasher that sanitizes; or employ an additional
sanitizing rinse in conjunction with the mechanical dishwasher; 8.Storage of bathroom items only.
or a 3 compartment sink or a 2 compartment sink with a third • • •
portable compart ment for the (trial sanitizing step. 1. If food preparation occurs, shall have a sink for food preparation
B. If a mechanical dishwasher is used, a minimum of two sinks separate from the diapering handwashing sink.
located in food preparation area designed for: 2. Utensils used in the Irr Unit washed, rinsed and sanitized after *-.,d
1)hand washing only 2)food preparation only, each use with proper methods and equipment.
9. Facilities with a capacity of more than 20 children approved before •
s% October 31, 1991,shall have: 1.No utensils washed,rinsed or stored in the diaper changing area.
A. Mechanical dishwashers that sanitizes;or employ an additional 2.Hand sink with warm running water located in the diapering area
sanitizing rinse in conjunction with a mechanical dishwasher;or immediately accessible to the diapering surface. `-
,'r,o`?
use a three vat sink. 3. Diapering surface smooth, easily cleanable, nonabsorbent, and in
B. If a mechanical dishwasher is used, a minimum of two sinks 9 repair.
located in food preparation area designated for: 4.Soiled diapers stored in a solid, nonabsorbent container with tight
1)hand washing only and 2)food preparation only. fitting lid located in diapering area. it
10. Facilities with a capacity of more than 20 children approved after 5.Soiled diaper container emptied, washed, rinsed and sanitized
tober 31, 1991 shall have: daily. n,
acili located in providers residence shall have separate food • "y`"" '
preparation and storage areas. 1.Adequate number of containers.
B. A commercial dishwasher or a 3 vat sink in addition to a separate 2.Clean,nonabsdrbant,in sound condition.
handwashing sink. 3.Outside refuse area clean;containers covered at all times.
4.Inside food refuse containers covered when not in use.
C. I! a commercial dishwasher is used, a sink located in food
'F preparation area designed for food preparation. •
°+ 1.Catered food from inspected and approved source.
2. Safe food temperature maintained during transport.
Temperature at arrival f'Sth'/r4,
3. Facility using catered food exclusively shall have a hand washing
sink in kitchen/lood service area. ^'+°
4. Facility not using single service utensils exclusively meets applicable
dishwashing requirements as stated in Section Ge,or G9,or G10.
Vt1+i,r
ve facility has'beefs inspected and ❑ does ❑ does not The inspector has discussed the issues marked by an asterisk (') on ,u s
CL m with the sanitation requirements of the MO Department of this form. I agree to comply with these requirements,
Health, Bureau of Child Care. I
sIGNATURE OF INSPECTOR TELEPHONE DATE SIGNATURE OF CHILD CARE PROVIDER DATE} K,
DISTRIBUTION:WHRF/BunEAU OF CHILD CARE CANARYANSPECTOR PINK/PROVIDER (x•95.2 ....d.
'3. .t0 5110.1916(9.99) 7
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EXHIBIT E xrri,� ,,,;- ..�coDES
P•cn x = Defects Noted.
�;•:.
MISSOURI DEPARTMENT OF HEALTH n Ti1° '''� m.o. =Nor Observed.
BUREAU OF CHILD CARE
p.m. N.A. = Na Asseda and agrees
SUMMER SCHOOL-AGE PROGRAM pa1C *
comply with r `�
- h9gUirerrfents.
SANITATION INSPECTION REPORT ./IC7 = Conforms to requirements,
❑Initial ❑Anrwal ❑Reinspection ❑ Lead ❑ Special Circumstance:
NAME DVN COUNTY CODE
FACILITY
ADDRESS(Street,City.State,Zip Code) INSPECTOR'S NAME (Print)
1. Premises dean and free of unsanitary conditions. 1. Food utensils and equipment washed,rinsed,sanitized,and air dried.
2. No evidence of environmental hazards. with MDOH approved methods.
3. No evidence of rodents or pest harborage. 2. Single service Items used only once.
4. Well ventilated, no evidence of mold,noxious or harmful 3. Food contact surfaces cleaned in place are washed,rinsed and
odors. sanitized with approved agents and methods.
5. No indications of lead hazards. 4. Chemical lest strips available to check proper concentration of
6. Medicines and other toxic agents not accessible to sanitizing agents._
children,and stored to prevent contamination of child 5. Soiled laundry stored and handled in a manner which does not
contaminate food and food related items,and child contact items.
contact items.
7. All sinks equipped with running water under pressure;
not to exceed temperature of 120'F. 1. Adequate number of containers.
Tern at the time of Ins ton: •F. can nova sorben,tnse a en proof.
e. Metal stemmed thermometer reading 0-220'F in 2'
i e re se tort hers cover a a times.
increments for checking food and water temperatures. = ' - • •
9. Swimming/wading pools filtered,treated,tested and Cleaned as needed.or at least daily.
s. water quality records maintained. Meets local codes. was ing s oq in,or immediately
is e y a taken o
10. Bathing beach used for swimming/wading purposes bathroom.
rY meets batting beach water quality standards. 3. All required equipment and fixtures in good repair.
No high hazard cross-connections• n wa ing facilities with running water prow Nri soap and
paper towels.
COMMUNITY •. NON-COMMUNITY PRIVATE 5. Sufficient lighting for cleaning. "'s
6. No carpets on floors.
=%a oottstruction prevents well contamination. 7. Storage of bathroom items only.Sample Results:
3. Transported water. 1. Salk lund es stored in a manner which prevents cross-
A. Water used far consumption is from an MDOH contamination by pests, toxic agents,leaning agents,water drain
approved source. lines,medicines,dust,splash and other foods.
B. Container property labeled. 2. Methods used by provider to transport sack lunches dean and free
C. Container properly washed,rinsed,and of unsanitary conditions.
;r sanitized at least once daily:and as frequently 3. Salk lunches brought from home for personal consumption only:
as needed. not shared with anyone else in the group.
;y - • •
y
COMMUNfTY ON-SITE
I. Utensils and food related items used to prepare and serve snacks
DNR Regulated System-Type: are single-use disposable items only,or are washed,rinsed and
DOH Regulated System-Type: sanitized between each use.
A. Functioning pcopt*N at time of insPW'On (circle) YES NO 2. Food,food related items and utensils covered and stored to
D Health hazard to children• (circle) YES NO prevent cross-contamination by pests, toxic agents,cleaning agents, k',•;;,
water drain lines,medicines,dust,splash and other foods.
1. Meets MDOH43CC requirements meets local requirements.
3. Food stored in food grade containers only.
fx
D. 4. Food from approved source and in sound condition.
;t
1, Caregivers and children wash hands using soap 5. Methods used by provider to Uansport food and food items are
running water and sanitary hand drying methods. dean and free of unsanitary conditions. :.
Caregivers;an children was hands after a e ng, 6. Potentially hazardous foods stored to meet temperature requirements f
assisting with laleting;nose blowing;before preparing or consumed within four(4)hours. oi
food:before and after eating;after handling raw food: 7. Refrigerator 41' F.or below:accessible readable thermometer
Q h .
cleaning and sanitizing;outdoor play:handling animals; required.
after smoking;and as necessary
ersonne preparing serving free o infection or illness. ❑ See Additional Page DC-112-2/This Repon Conutna Additional paun,entatlon
The above facility has been inspected and does oes not The tnspectix has discussed the issues marked by an asterisk(*)and/or
Hr
"? conform with the saniWGon requirements of the MO Department of marked by an(X)on this form. I agree to comply with these requirements.
i Health,Bureau of Child Care.
DATE
SIGNATURE OF INSPECTOR TELEPHONE DATE SIGNATURE OF CHILD CARE PROVIDER s:
t � �.. .,W s "�k"•j'r��,w,•}*y,-":""..._�,.��5{(' �'3t;�c�«-fin ; ,., ,T„
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a 3{!. ',��`�"+.1:1}. J�s�rvi•+ � � .� 5a fJ 1:n�+'',�`•,+, r`f� �+-,,.k
;'� u 4t? '•,.d ki' f+�tt� i Lfi'1�,' .t
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PACILRY NAME DVN
r
.p . •-IT • • . • • 1i • • i,•rf.{.
from approved source and in sound condition:no S. Facilities shall have mechanical refrigeration for childcare use only,
rk " cessively dented cans. 6. No carpeting or absorbent floor coverings in food preparation area.
food,food related Items and utensils covered and stored to 7. Adequate preparation and storage equipment for foods.
i`
prevent cross-confaminallon by pests•toxic agents,cleaning agents, 8. Kitchen sinks supplied with a minimum water temperature of 100'F. „r'=;;•'
water drain lines,medicines,dust,splash and other foods. 9,
3. Food stored in food grade containers only, A. Mechanical dishwasher that sanitizes:or employ an
4, No food or food related items stored in bathrooms. additional sanitizing rinse in conjunction with the mechanical I
S. Refrigerator 41'F.or below;acce ssible readable thermometer dishwasher:or a 3 compartment sink:or a 2 compartment sink x + tA
required. Foods in freezer frozen solid. 'F. with a third portable compartment for final sanitize step.
6. No use of home canned food.No unpasteurized milk/juice. B. If mechanical dishwasher is used,a minimum of two sinks ;art,tif?+•' '
". .y: 7. Ground beef cooked to 155'F:poultry to 165'F:pork to 150'F located in the food preparation area designed for:
and all other foods cooked to at least 140'F.or above. 1)hand washing only 2)food preparation only.
8. Precooked food reheated to 165'F. 10. '
9. Food requiring refrigeration stored at 41'F.or below. r
f 10. Food,toxic agents and cleaning agents not in their original A. Mechanical dishwasher that sanitizes;or employ an
containers shall be property labeled. additional sanitizing rinse in conjunction with the mechanical
11. Food thawed under refrigeration, under running water 70'F.or dishwasher,or a 3 compartment sink.
below or in microwave if art of the cooking process. B. If mechanical dishwasher is used,a minimum of two sinks
pt� P g :�l: ;tr•.r.
12. Food served and not eaten is not re-served to children in care. located in the food preparation area designed tor:
at 13. Methods used by provider to transport food and related items 1)hand washing only 2)food preparation only.
`t,f
k dean and free of unsanitary conditions. 11. e
14. Potentially hazardous foods transported to other locations shall 0
be stored to meet temperature requirements or be consumed A. Facility located in providers residence shall have separate
within 4 hours from time of preparation. food preparation and storage areas.
�r
` e • •
DITIMMM. kilo
B. A commercial dishwasher or a 3 vat sink,in addition to a r r qq
�'''��k r` S'•
service items not reused. se
1 Single P g s„,• ,;f;,
. separate washing sink.
2. food equipment and utensils in good repair. C. If a commercial dishwasher is used,a sink located in food
' preparation arxi storage areas have adequate lighting. preparation area,designed for food preparation, r M
z e
k7j en equipment that produces excessive grease laden vapors ((rf rf ric t
=lure or heat are property vented. a ^` `
4C•c�1r:
";Y":Y�; '{•i"``3,�°i#..,fir"
l ;
s 4!r aciii has been Inspected and 0 does Lj does not The inspector has discussed the issues marked by an astensk and/or •
tr kr ilu-i with the sanitation requirements of the MO Department of marked by an(X)on this form. I agree to comply with these requirements
" ¢t 31th, Bureau of Child Care. x, '
NATURE OF INSPECTOR TELEPHONE DATE SIGNATURE OF CHILD CARE PROVIDER DATE A
t
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EXHIBIT F Pap I of 1
ARRNAL TIME A.M 'i+,l`;i'`:'i`',•+'; +'
MISSOURI DEPARTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY AND LICENSURE P,M
FIELD MONITORING SUMMARY FORM DEPARTURE TIME A•M,
P.M
�L Initial ❑Annual ❑ Reinspection ❑ Lead ❑ Special Circumstances:
UVN
`s FACILITY NAME '-'•rii;,;<i i1 .
INSPECTOR'S NAME(Print)
ADDRESS(Street.City.Seta:21p Code) a
Educational Materials Available
.
Thoroughness of Inspection Technical Knowledge
Appropriate Discussion Times BCCSL Policy Knowledge
Exit Interview
Introductory Phase Use of Proper Equipment r>.`{`;`1 ,:•
Understandability Inspection Forms on Hand
I`...;'S'O'S° �J•:h 4't`).
Tai��'�it�..i'•y
5 •�}.9 rY`L �.5.ii`r
:La1t�'"V�f
LOCAL INSPECTORS SIGNATURE DATE
^.'t.ij;,.li ...CSL pEPFiSSIGNATURE
;'{ ^• r E
� e
fk ,
Fi
DISTRIBUTION: WHITE—BCCSL/EPHS: CANARY—Lo al ealttt Ap�ncy
MO 500.2340(5-99)
4 s x 7
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t
EXHIBIT G
Page I of t
MISSOURI DEPARTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY AND LICENSURE
DESK MONITORING SUMMARY FORM
,;. COUNTY 1 C17Y
toa:
NAME OF BCCSL STAFF
Quarter: 1❑ 20 3❑ 4[' (check one)
V MIT IT,
2.
3.
4.
5.
MEM
1, Y❑ N❑
1. Y❑ N❑
2. Y❑ N[-] 2. Y❑ N❑
3. Y❑ No 3. Y❑ N❑
4. Y❑ No
4. Y❑ N❑
5. Y❑ N[:] 5.Y❑ N❑
P use of Inspection Form Codes,accuracy and clan of the Notes section,etc.
N❑
" a
2. Y
N[:]
4. Y❑ N❑
5. Y❑ N❑
as
No Action Necessary (NL) Not Legible (NUR) Nursery School
] Telephone Conference (NSI) Not Sanitation Issue (DC) Day Care Center -
] w/Ins and Administrator NCP Not Coded Properly (FILE) Religious License Exempt 1 ,
Conference Req. p• ( ) h
] Addition Training Required (RR) Reinspection Required (FH) Family Home aYt' 4' .
] Referred to Central Office of BCCSL (NP) Not BCCSL Policy (GH) Group Home
(NR) Not Recorded (Y) Yes �yt
ENC Ent Not Clear (N) No
( ) Entry TITLE: DATE: iksz
'S SIGNATURE
0C-111
DISTI OLMON:vMjTE-BCCSL I EPHS: CAXAIIY-Lod""Lh Agency
580.23'11(5.99 ;..lir
lAi, S
f A
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•• • '.t
EXHIBIT H 4• ;
Page 1 of 1 t r �
j?
BUREAU OF CHILD CARE ENVIRONMENTAL
PUBLIC HEALTH SPECIALIST STAFF
:- Child Care Sanitation Inspection Contacts
NAME LOCATION
a. .x
Dave Bordner, EPHS V Bureau of Child Care - f ,
u, "t• ':i
573/751-2450 Division of Health Standards and Licensure
Fax: 573/526-5345 912 Wildwood ' '
P.O. Box 570
Jefferson City, MO 65102
= s:}
w;W' ?
Bill Smith, EPHS III Central District Health Officer
573/751-2891 Child Care Unit
�A.r•
Fax: 573/752-0247 1715 Soutluidge Drive
r;nx �
Jefferson`City,MO 65109
} r.1
Jerry Bertoldie, EPHS III Southwestern District Health Office
.,
„r 417/895-6541 Child Care Unit
'-' Fax: 417/895-6994 1414 West Eflindale
a
,t3 P.O. Box 771, MPH
;alb. Springfield, MO 65801
:;�• ,:� � tip'-* �r�;,�."
Judy Welsh, EPHS III and Northwestern District Health Office
r rYrV
Cheryl Murphy, EPHS III Child Care Unit
13901 Noland Court
`•�� 816/325-5860
r. Independence, MO 64055x '
•�;5., Fax: 816/325-5878
i'
. y:...r
John Smith, EPHS III and Eastern District Health Office
t_. Child Care Unit
r:„• ` Dale Lindberg, EPHS IlI ": �•
220 S. Jefferson, 2"d Floor
314/877-0210
Fax: 314/877-0203 St. Louis, MO 631031 '
u;
{
Paula Cates, EPHS III
Southeastern District Health Office Al
V 573/840-9720 Child Care Unit
;,
Fax: 573/840-9727 2875 James Blvd. r
. Poplar Bluff, MO 63901
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• EXHIBIT J
MISSOURI DEPARTMENT OF HEALTH
J BUREAU OF CHILD CARE Pagel of 2 "r
VARIANCE REQUEST
yi§I•s.
i • -tongs AGES SERVED }'c..
CAPACITY
IACILITY NUMBER
< FACILITY TYPE FamII Home
Llcensed: ❑ Center ❑ Group Home ❑
Refi ious Organization Nurse School Summer Cam Other
License-Exempt: FACILITY PHONE NUMBER ?;`• r; • ?y- r;j
FACILITY NAME
COUNTY s',I;t.4,�
FACILITY ADDRESS }'•'•' ;;,;.':;•'j;(
TITLE I POSITION DATE
LICENSEE I DIRECTOR REQUESTING VARIANCE
I am requesting a variance from rule 19 CSR 30- (F711 In Rule Number Here) i
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Please explain why you are request Ing a variance. Submit any documents,photoaphs or other IntormaUon which verifies that the health and safety or children will
not be endangered by approval of this request. (Attach additional sheets as necessary.) "'• `' ;'
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1
RE OF LICENSEE/DIRECTOR NOTE:,PLEASE RETURN COMPLETED FORM TO YOUR :'; ;.•._f ;;,_
" CHILD CARE SPECIALIST. THANK YOU!
CONDITIONS OF APPROVAL:
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PROVIDER DISTRICT '•''''<r
;y? RULE NUMBER ❑ NW ❑ NE ❑C ❑SW ❑ SE ❑E
55..3
a` ❑ FINAL APPROVAL
' I ❑ LEVEL It ❑ LEVEL I11 ;',,
*'✓�� ❑ LEVEL � r w
`�} DATE CHILD CARE SPECIALIST I EPHS
roved w/conditions ❑Denied
ved ❑APP suPEFrnso
❑ R
DATE CHILD CARE
r- ved ❑Approved w/conditions ❑Denied
DISTRICT SUPERVISORSt,,`S
[j Approved ❑Approved w/conditions [3 Denied
DATE DOH CONSULTANT(S)
❑Approved ❑Approved w/conditions ❑ Denied
DATE BUREAU CHIEF
Denied
Approved w/conditions ❑
❑Approved ❑ PP _..__.._-- --•--•• ----- �+c.
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Page 2 of 2
MISSOURI DEPARTMENT OF HEALTH '
' BUREAU OF CHILD CARE SAFETY AND LICENSURE
VARIANCE REQUEST I INTEROFFICE COMMUNICATION
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FACILITY NUMBER DATE •t`si{ <.'
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CHILDCARE REPRESENTATIVE
CHILD CARE SUPERVISOR
• ',����:�,�.F 1`•s;°tai
\! DISTRICT SUPERVISOR
CONSULTATION/ EXPERT OPINION''
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BUREAU CHIEF
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