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BiLL NO._„_,,, 97-121
SPONSORED BY COUNCILMAN Landwehr
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ORDINANCE NO. 1 '
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AN ORDINANCE OF THE CITY OF JEFFERSON, MISSOURI, AUTHORIZING THE
MAYOR AND CI'TY CLERIC TO EXECUTE AN AGREEMENT WITH COLE COUNTY
HEALTH (DEPARTMENT FOR PAYMENT OF CHILD ^ARE FACILITY INSPECTIONS. �
BE IT ENACTED BY THE COUNCIL OF THE CITY OF JEFFERSON, MISSOURI, AS f
FOLLOWS:
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Section 1. The Mayor and City Cleric are hereby authorized and directed to execute 1
an agreement with Cole County Health Department for Payment of Child Care Facility
Inspections.
Section 2. The agreement shall be substantially the same in form and content as
that agreement attached hereto as Exhibit A.
Section 3. This Ordinance shall be in full force and effect from and after the date of
its passage and approval.
Passed: �a . . Approved:
Presidia Officer Mayor
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ATTEST: APPROVED AS TO FORM:
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AGREEMENT
Cole County Health Department intends to contract with the City of Jefferson(Subcontractor-SC)for
the performance of certain tanks;
? WHEREAS,SC is identified as follows:
Name: City of Jefferson
Type of entity:
[ j Sole proprietorship [ ) Professional corporation [ ) Individual
' [ j Partnership [xj Corporation - municipal
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Principal place of business: 320 East McCarty Street, Jefferson City, Missouri, 65101. y
Business 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 Comity #
Health Department is not SC's sole and only client or customer. t
THEREFORE, IN CONSIDERATION 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
r conditions set forth in Section 4.0, Invoice/Reporting, of the attached Scope of Work. Cole County Health
Department will retain ten percent(10%)of accounts received for administrative costs. Any other covered expenses
1 will require prior authorization by Cole County Health Department.
�3. PAYROLL OR EMPLOYMENT TAXES. Neither federal,nor state, nor local income tax, nor payroll tax
of any kind shall be withheld or paid by Cole County Health Department on behalf of SC or the employees of SC.
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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 the other.
6. Contract shall be for period from October 1, 1998 through September 30, 1999.
Agreed to this-L�day of h, J?,l'., 1998 at Jefferson City, State of Missouri.
-; COLE COUNTY HEALTH DEPARTMENT CT. OF JEFFERSON,MISSOURI I�
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AGREEMENT
WHEREAS,Cole County Health Department intends to contract with the City of Jefferson(Subcontractor-SC)for the
performance of certain tasks;
WHEREAS,SC is identified as follows:
Name: City of Jefferson
Type of entity:
[ ] Sole proprietorship [ ]Professional corporation [ ]Individual
[ ] Partnership [x] Corporation-municipal
Principal place of business: 320 East McCarty Street,Jefferson City,Missouri,65101.
Business 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 ten
percent(10%)of accounts received for administrative costs. Any other covered expenses will require prior authorization
by Cole County Health Department.
•3. PAYROLL OR EMPLOYMENT TAXES. Neither federal,nor state,nor local income tax,nor payroll tax of any
kind shall be withheld or paid by Cole County Health Department on behalf of SC or the employees of SC.
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
the other. /
6. Contract shall be for period from October 1, 1999 through September 30,2000.6,, � aGJ
Agreed to this qday of rn �' ,2000 at Jefferson City,State of Missouri.
COLE COUNTY HEALTH DEPARTMENT CITY OF JEFFERSON, SS URI
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C ty Auditor City erk
APPRO AST M:
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H:\Secretary\Contmct Fileslmisc k's\tole county health dept\ag Bement 1999-00-pd
Local Sanitation Inspections for Child Care Facilities
SCOPE OF WORK
October 1, 1999 through September 30,2000
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 timely 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,pest control, safe water supplies, safe on-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 Department's Bureau of Child Care(BCC)
District/Area office will forward a Request for Child Care Inspection, DC-33 (Exhibit B)
to the Contractor. The following inspection forms,dependent on the type of facility,
shall be used to document the results of the inspection:
a) Sanitation Inspection Report/Family Child Care Home. DC-34 (Exhibit C)
b) Sanitation Inspection Report/Licensed Centers Group Homes and
License-Exempt Facilities, DC-35(Exhibit D)
Sanitation Inspection Reports, (DC-34 and DC-35)will be provided to the
Contractor upon request to the BCC District Office.
2.2.2 The Contractor shall contact the provider within 10 working days of receipt of the
Request for Child Care Inspection(Exhibit B)to establish a mutually agreeable time for
the initial 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.
The completed initial Sanitation Inspection Report(DC-34 or DC-35)and the Request
for Inspection (DC-33)shall be received by the BCC Central Office within 10 working
days of the inspection.
2.3 Conduct Annual Sanitation Inspections for existing child care facilities.
2.3.1 A Request for Child Care Inspection(DC-33)shall be sent to the Contractor by BCC
District/Area Office at least 60 days prior to the inspection due date. One of the
following inspection forms,dependent on the type of facility,shall be used to document
the results of the inspection:
a) Sanitation Inspection Report/FagmMg Child Care Home. DC-34(Exhibit C)
b) Sanitation Inspection Report/Licensed Centers Group Homes and License-
Exempt Facilities, DC-35(Exhibit D)
2.3.2 The annual inspection shall occur by the inspection due date as indicated on the DC-
33. The appropriate,completed Sanitation Inspection Report(DC-43 or DC-35)shall
be received by the BCC Central Office within 10 working days of the inspection.
•
2.4 Conduct Reinspections for those facilities not approved as.a result of the initial or annual
inspections.
2.4.1 For initial inspections, if a reinspection is necessary, it shall occur within 20 working
days after the initial inspection, or as agreed upon by the Contractor and provider.The
reinspection report(also submitted on a DC-34 or DC-35)shall be 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 Section 2.5.1.
2.4.2 For annual inspections, if a reinspection is necessary, it shall occur by the inspection
due date as indicated on the DC-33. The reinspection report(also submitted on a DC-
34 or DC-35)shall be 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 Section 2.5.1.
2.5 Conduct Special Circumstance Sanitation Inspections arising from unique circumstances
such as emergency situations, disease outbreaks,exposure to environmental hazards,
reports of rule violations (complaints), or continued noncompliance after reinspection.
2.5.1 Special circumstances requiring additional inspections (beyond the initial, annual and/or
one reinspection)shall be initiated through a verbal or written request by the BCC or
the Contractor and be based on the availability of the Contractor. The special
circumstance inspection report(also submitted on a DC-34 or DC-35)shall be 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.
2.6 Conduct Lead Inspections for those facilities where a lead hazard has been indicated.
2.6.1 Lead inspections shall only be conducted by a licensed lead inspector.
2.6.2 Lead inspections 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 District
Environmental Public Health Specialist(DEPHS)in order to conduct a lead inspection.
Written approval (DC-33)is required in order to be reimbursed for a lead inspection.
2.6.3 A lead inspection may also be initiated by the Contractor. Verbal or written approval
(DC-33) is required from the BCC District Environmental Public Health Specialist
(DEPHS) in order to conduct a lead inspection. Written approval (DC-33)is required in
order to be reimbursed for a lead inspection.
2.6.4 A lead inspection report shall be received by the BCC within 10 working days of the
lead inspection. A copy of the DC-34 or DC-35,with all identifying information at the
top of the form completed, must be attached to the lead inspection report.
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8/12199 2
2.7 Required Child Care Sanitation Inspector Qualifications/Training
The Contractor shall assure their inspectors successfully complete the following:
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2.7.1 Sanitation Inspector Qualifications
Child Care Sanitation Inspectors shall qualify at the level of Environmental Public
Health Specialist I or above and have at least six months of work experience in the field
of environmental health.
2.7.2 Initial Required Training
Initial required training shall be completed prior to approval of inspection
reimbursement.
3.0 Monitoring/Training
3.1 BCC DEPHS will provide annual classroom instruction for all participating inspectors. 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.
3.3 The Contractor shall follow all BCC policies and procedures regarding variance requests from
providers. Training will be provided by the BCC in the process for handling variance requests
from providers. All variance requests must be documented on the Variance Request Form
(DC-25-1 and DC-25-2)(Exhibit E)and submitted through the appropriate channels. Various
types of common requests and documentation practices are contained in Chapter VI of the
Child Care Sanitation Inspection Manual. Forms shall be made available through the BCC
District Offices.
3.4 Quarterly Child Care Inspector trainings will be conducted as needed to address training for
new or additional employees wishing to provide child care sanitation inspections.
3.5 Field Training/Monitoring
3.5.1 The BCC DEPHS's will accompany each previously contracted local Inspector on at
least four field monitoring inspections to include two family homes,one center, and
one religious organization. All four of these facilities shall involve infant/toddler care.
3.5.1.1 The Contractor shall contact the BCC DEPHS's and schedule these field
monitoring inspections. A minimum of one field monitoring inspection shall be
completed per quarter unless all four field monitoring inspections have been
completed earlier.
3.5.2 The BCC DEPHS's will accompany each newly contracted and/or new local Inspector
on the following types of inspections:
1) two field monitoring inspections in centers and/or group homes involving
infant/toddler care;
2) two family homes involving infant/toddler care;
3) one nursery school; and
4) one religious organization involving infant/toddler care.
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8/12199 3
3.5.2.1 The Contractor shall contact the BCC DEPHS's and schedule these field
monitoring inspections. A minimum of one field monitoring inspection shall be
completed per quarter unless all six field monitoring inspections have been
completed earlier.
3.7 Technical Assistance
3.7.1 All technical assistance relating to inspection issues shall be directed to the BCC
District Environmental Public Health Specialists in their respective district offices
(Exhibit F).
4.0 INVOICING/REPORTING
4.1 The Contractor shall request reimbursement for services provided based on the following
payment schedule and shall be billed using the Reimbursement Request for Child Care
Sanitation Inspection form(DC-38-1 and DC-38-2)(Exhibit G).
4.1.1 Indirect costs, as defined in OMB Circular A-87, shall not exceed eight(8)percent of
total contract costs. Indirect costs are those costs incurred for common or joint
purposes benefiting more than one activity and not readily identifiable to a particular
program or activity.
4.2 Reimbursement Rates
Reimbursement rates for annual and reinspections shall be based on the established time
frames in Section 2.0. Annual and reinspections 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. ,
The Contractor shall be reimbursed at a rate not to exceed the following:
4.2.1 $70.00 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
technical assistance to providers.
4.2.2 $40.00 per reinspection 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 $25.00 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.)
4.2.4 $25.00 shall be reimbursed to Contractor when the BCC requests an inspection and
upon arrival at the facility, it is found to be no longer in operation.
4.2.5 $40.00 per hour for lead inspections 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.
NOTE: The quoted reimbursement Cates 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 contract.
8112199 4
4.3 Reimbursement/Procedures
4.3.1 A Reimbursement Request for Child Care Sanitation Inspections(Exhibit G)must be
completed on a monthly basis and submitted to:
Bureau of Child Care
Missouri Department of Health
P.O. Box 570, 920 Wildwood
Jefferson City, MO 65102
Invoices shall be submitted by the last day of the month following the month of the
inspection, (i.e., if the inspection is completed in May, the Reimbursement Request
(DC-38)for the billing month of May must be submitted no later than June 30.) Invoices
received after the required deadline will be ineligible for payment. Incomplete invoices
shall be returned to the Contractor for completion which will delay the reimbursement
process. Final invoices shall be submitted prior to October 31,2000.
4.3.2 All Sanitation Inspection Reports(DC-34's and DC-35's)shall be submitted within 10
working days of the actual inspection. These reports will be collected in BCC 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
all Child Care Inspection Reports (DC-34's and DC-35's)have been submitted prior to
sending the monthly Reimbursement Request for Child Care Sanitation Inspections
(DC-38).
4.3.3 No reimbursement shall be paid for work done prior to completion of the initial required
child care inservice training.
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
Jefferson City, Phone Number; 5731751-2450.
5.0 SPECIAL PROVISIONS
5.1 Child Care Sanitation Inspection Manual
5.1.1 This manual is a basic guide to the Missouri Department of Health, Bureau of Child Care's
inspection program regarding sanitation inspections conducted in child care facilities.
The Contractor shall adhere to all policies, procedures and requirements contained in
this manual and all its revisions.
General instructions relating to the submission of invoices for reimbursement of monthly
billings are included in the Child Care Sanitation Inspection Manual. Assistance for invoicing
questions will be available through the Department's Bureau of Child Care Central Office at
5731751-2450,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 rule
or regulation promulgated pursuant to this section. The request for a variance shall be
made in writing to the Department and shall include the reasons the facility is requesting
the variance. The Department shall approve any variance request that does not
endanger the health or safety of the children served by the facility. The burden of proof at
any appeal of a disapproval of a variance application shall be with the Department. Local
• inspectors may grant a variance,subject to approval by the Department."
The Contractor shall adhere to all policies,procedures, and requirements regarding
variances as stated in Chapter VI of the Child Care Sanitation Inspection Manual.
8112199 5
Contractors shall submit a written recommendation on any variance that is submitted from
their respective facilities, along with any supportive documentation from which they based
their decision. The variance form (Exhibit E)will be sent to the BCC DEPHS for review.
Variance forms shall be available through the district BCC office and training will be provided
on variance procedures and forms at the district training sessions.
5.3 Multiple County Contracts
5.3.1 In those instances when the Contractor wishes to provide child care sanitation
inspections outside their immediate designated city/county, a letter of agreement
between the respective agencies,signed by all participating administrators, shall
accompany this signed contract and be returned to the Department. Documentation
should include a listing of all entities for which reimbursement is expected and
indicating the lead agency to which reimbursement is to be made.
5.4 Sanitation Training to Providers
5.4.1 The BCC will not reimburse inspectors for sanitation training to child care providers
through this contract, however,training for providers can be coordinated and billed
through the Department's Bureau of Nutrition and Child Care Programs, Child Care
Health and Safety Consultation contract. Any sanitation training must be coordinated
with the appropriate local or district Child Care Nurse Consultant and BCC District
Environmental Public Health Specialist.
5.5 The Department's Bureau of Child Care will provide all forms(Exhibits A-G)required for this
contract.
5.6 The BCC reserves the right to contact child care providers periodically to monitor quality
assurance. The BCC also reserves the right to conduct sanitation inspections in contracted
areas to monitor quality assurance. Future contract offers may be based on quality service
• history.
•
8112/99 6
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Licensed License-Exemat Cion-Ben a
Required by Statute to be Licensed 1. Exempt from Licensure, but Required Exempt from Any Statewide
by Statute to be Inspected Regulation or Inspection
• Family Homes • Religious nraanizations • Child Care Facilities operated by
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Caring for 5 - 10 Children A Child Care Facility that operates under the School Systems (Private and Public)
exclusive control of a religious organization
• Business for convenience of
♦ Group Homes
Customers (No child care for
Caring for 11 - 20 Children ♦ LyurserY Schools
A program for preschool children that is employees' children)
• Child Care Centers operated for no more than four (4) hours per
Caring for 21 or more Children child, per day, and is aal under the exclusive ♦ Religious Organization Academic
control of a religious organization. Preschools exclusively for 4 and 5
♦ Head Starts' year olds
♦ Sum neLCams
A program operated from May to September ♦ Vacation Bible Schools
*Are licensed as Child Care Centers by a person or organization with the primary
function of providing a summer recreational ♦ Child Care Facilities caring for four (4)
program for children no younger than five or fewer children
(5) years of age and providing no child care
for children younger than five (5) years of ♦ Registered Providers
age.
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EXHIBIT B
STATE OF MISSOURI
MISSOURI DEPARTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY AND LICENSURE
REQUEST FOR CHILD CARE INSPECTION
Request Date: 99/99/9999
Child Care District Office:
Local Health Office or Fire Marshal's Office: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx(sanitation)xxxxxxxxxxxx xxxxxxxxxxxx(address)xxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxx(address)xxxxxxxxxxxxxxxxxx xxxxx(csz)xxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxx(csz)xxxxxxxxxxxxxxxxxxx xxxx(worker)xxxxxxxxxxxxxxxxxxxxxxxxxxx
Phone: 999/999-9999
Facility #: 999999999
xxxxxxxxxxxxxxxx(name)xxxxxxxxxxxx Annual Expiration Date: 99/99/9999
Contact: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Phone: 999/999-9999
xxxx(address)xxxxxxxxxxxxxxxxxxxxxxx
County: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Directions to Facility:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Type of Facility: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Initial License/Approval: Begin Date: 99/99/999 End Date: 99/99/9999
Age Range: 999 (under 2) 999 (over 2) Capacity: 999
Shifts:
Limitations:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Reason for Inspection: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Change in: Capacity Age Range Building/Heating System
Comments:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxXxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
7/1/98 DISTRIBUTION• BCCSL Central Office,BCCSL DEPHS, Local Agency,Provider DC-33 (HDCRP033)
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EXHIBIT C
MISSOURI DEPARTMENT OF HEALTH Ami Tr'*'e qMN7N BUREAU OF CHILD CARE SAFETY ANDLICENSURE tects Noted
4 Depanure Tune ot Observed
SANITATION INSPECTION REPORT EEocusseda n
FAMILY CHILD CARE HOME DATE =Discussed and Agrees to
comply with requirements
❑ Initial ❑Annual ❑ Reinspection ❑ Lead ❑ Special Circumstances: DVN COUNTY CODE
NAME
INSPECTOR'S NAME (Print)
t ADDRESS ($IrKI Cny $tale ZED CODe)
An inspection of the premises of your facility has been made on the above date. Any defects are marked below with an X.
1- Premises clean and free of unsanitary conditions. 1.Food from approved source and in sound condition:
no excessively dented cans.
2. Premises free of environmental hazards. 2.No use of home canned food. No unpasteurized milk.
3. No evidence of insects,spiders,rodents or pest harborage- 3_If meals are served,kitchens shall have adequate equipment to
i 4. Well ventilated.no evidence of mold,noxious or harmful odors. store and prepare food safely with a minimum of a stove or other
cooking equipment sized to meet the needs of the facility:a two
5. Screens on windows and doors used for ventilation in good repair. compartment sink with hot and cold running water:and a
6. No indication of lead hazards. refrigerator.
7. No toxic or dangerous plants accessible to children. 4. Ground beef cooked to 155' F.poultry to 165' F.
8- Medicines and other toxic agents not accessible to children pork to 150'F:and all other foods cooked to at
and stored to prevent contamination of child contact items. least 140'F_ All hot food kept at 140'F or above.
9, All sinks equipped with mixing faucets or combination faucets 5. Precooked food reheated to 165'.
with hot and cold running water under pressure. 6. Food requiring refrigeration stored at 41' F or below
10. Hot water temperature at sinks accessible to children•100'-120'F 7, Refrigerator 41'F or below,accessible readable
Temp at time of Inspection thermometer required. Foods in.freezer frozen solid.
g_ Metal stemmed thermometer reading 0-220'F.in 2'increments
11. Pets free of disease communicable to man. for checking food temperatures.
12. Pel living quarters dean,and well maintained. g.Food,food related items and utensils covered and stored to prevent
13- Reptiles are prohibited on the premises. Birds of the Parrot Family contamination by pests,toxic agents.cleaning agents,water drain
tested for Psittacosis. lines,medicines.dust,splash and other foods.
14- Swimmingtwading pools filtered,treated,tested and water 10.Food.toxic agents,cleaning agents not in their original
quality records maintained. Meets local codes. containers shall be 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
,yPRIV/1TE SYSTEMS ONLY? '. E�! or microwave if part of the cooking process.
1. Constructed to prevent contamination. 14-No animals in food preparation area-
l. Meets MDOH-BCCSL requirements I meets local requirements 15.No eating,smoking,drinking during food preparation.
A. Bacteriological sample results-
B. Chemical(Prior BCCSL Approval Needed) 16.Food served and not eaten shall not be re-served to children in care.
•
COMMUNITY ON-SITE 1. Food utensils washed,rinsed and air dried.
DNR Regulated System-Type: 2. Single service items used only once.
3. Food contact surfaces cleaned in place are washed.
DOH Regulated System-Type: rinsed and sanitized with approved agents.
1. Functioning properly at time of Inspection.(circle) Yes No 4. Infant/toddler toys washed,rinsed and air dried after
2. More than three acres. (crde) Yes No contact with body fluids,when soiled or at least daily.
3. Health hazard to children_ (6rde) Yes No 5. Diapering surface and potty chairs washed,rinsed and
Meets MDOH-BCCSL requirements I meets local requirements sanitized after each use with approved agents.
6. Test kits available to check proper concentration of
SAL
1. Care givers and children wash hands using soap,warm sanitizing agents.
running water and sanitary hand drying methods. 7. Soiled laundry stored and handled in a manner which does not
2. Care givers and children wash hands after toileting,diapering, contaminate food and food related items and child contact items.
assisting with toileting and nose blowing:before preparing food:after - •
handling raw food,cleaning and sanitizing,outdoor play,handling 1. Adequate number of containers.
animals,smoking and as necessary. 2. Clean•nonabsorbent,insect and rodent proof.
3. An empty sink available in kitchen to wash hands during food 3. Outside refuse containers covered at all times.
preparation.
4. Hand sink with warm running water accessible at all times to wash 4. Inside containers covered when full or accessible to children.
hands after using bathroom and diapering. 5. Soiled diapers stored in solid•non absorbent container with
tight fitting lid located in the diapering area.
i Family Child Care Home
Sanitation Inspection Report
DVN:
Facility Name:
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n does does not inspector has discussed the issues marked by an asterisk
The above facility has been inspected and ❑ ❑ The Insp
conform with the sanitation guidelines of the MO Department of ��)on this form- I agree to comply with these requirements.
Health.Bureau of Child Care Safety and Licensure
SIGNATURE OF INSPECTOR TELEPHONE DATE SIGNATURE OF CHILD URE PROVIDER
DATE
EXHIBIT D
MISSOURI DEPARTMENT OF HEALTH ArTYalT'm am CODES
BUREAU OF CHILDCARE SAFETY AND LICENSURE P�,i X =Detects Noted
�nu a TK.+e a,,, N.O. =Not Observed
w 1 HEALTHlSANITATION INSPECTION REPORT p,,, N.A. =Not Applicable
=Discussed and
LICENSED CENTERS. GROUP HOMES to
GATE comply with requirements
AND LICENSE-EXEMPT FACILITIES
I ypeot'"spec S ectal Circumstances
❑ Initial ❑ Annual ❑ Reinspection ❑ Lead P
DVN COUNTY CODE
l NAME
INSPECTOR NAME(PLEASE PRINT)
IADDRES5 (Slreel Cay Slate.Zm Cooe)
j An inspection of the premises of your facility has been made on the above date. Any defects are marked below with an X.
E. • • • PROTECTION
1. Food from approved source and in sound condition:
1. Premises clean and free of unsanitary conditions. no excessively dented cans.
2. Premises free of environmental hazards. 2. No use of home canned food No unpasteurized milk.
3. No evidence of insects.spiders.rodents or pest harborage. 3. Ground beef cooked to 155' F.poultry to 165' F:
4. Well ventilated,no evidence of mold,noxious or harmful odors. pork to 150"F:and all other foods cooked to at
j 5. Screens on windows and doors used for ventilation in good repair. Precooked 140*F.
All
lrhot food
to6
od pat 140'F or above.
4
6. No indication of lead hazards.
F or below.
7. No toxic or dangerous plants accessible to children.
5. Food requiring refrigeration stored at 41'
ow,accessible readable
a. Medicines and other toxic agents not accessible to children 6_Refrigerator 41' F or bel
and stored to prevent contamination of child contact items. thermometer required. Foods in freezer frozen solid.
9. All sinks equipped with mixing faucets or combination faucets 7. Metal stemmed thermometer reading 0-220' F.in 2'increments
with hot and cold running water under pressure.
for checking food temperatures.
10. Hot water temperature at sinks accessible to children,100'-120'F. 8. Food.
contamination oelated by pitemstand utensils covered gents.cleaning agents.stored
water prevent
Temp at time of Inspection
lines,medicines.dust,splash and other foods.
11. Pets free of disease communicable to man. g_ Food•toxic agents,cleaning agents not in their original
12. Pet living quarters clean•and well maintained. containers shall be labeled.
13. Reptiles are prohibited on the premises. Birds of the Parrot Family 10.No food stored or prepared in diapering area or bathrooms.
tested for Psittacosis. 11.Food stored in food grade containers only.
14. Swimmingtwading pools filtered,treated,tested and water 12 Food thawed under refrigeration.70'F running water
quality records maintained. Meets local codes. Dr microwave if part of the cooking process.
13.No animals in food preparation area.
PRIVATE 14.No eating•smoking,drinking during food preparation.
COMMUNITY NON-COMMUNITY
HIGH HAZARD CROSS CONNECTIONS 15.Food served and not eaten shall not be re-served to children in care.
PRNATE.SY.STEMS ONLY:;;;
1. Constructed to prevent contamination.
1. All food equipment,utensils and food contact surfaces
2. Meets MDOH-BCCSL requirements/meets local requirements washed,rinsed and sanitized with approved agents.
A. Bacteriological sample results. concentrations.and methods.
B. Chemical(Prior BCCSL Approval Needed) 2: All utensils and toys air dried.
I 111;j 3. The following items washed,rinsed and sanitized after each use.
COMMUNITY ON-SITE A. Food utensils
urfaces including eating surfaces,high chairs.etc.
DNR Regulated System-Type: B. Food contact s
DOH Regulated System-Type: C. Potty chairs
1. Functioning property at time of Inspection.(circle) Yes No D. Diapering surface
2- More than three acres. (circle) Yes No E.'Infant/Toddler 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,
Meets MDOH-BCCSL requirements/meets local requirements A. Toilets.urinals,hand sinks.
• B. Non-absorbent floors in infanVtoddler spaces.
. HYGIENE
1. Care givers and children wash hands using soap.warm C. InfanUtoddler toys used during the day
running water and sanitary hand drying methods. 5. Carpets spot cleaned and sanitized when contacted
2. Care givers and children wash hands after toileting,diapering• by body fluids.
assisting with toileting and nose blowing;before preparing food: 6.Test kits available to check proper concentration of
after handling raw food.cleaning and sanitizing•outdoor play, sanitizing agents.
handling animals,smoking and as necessary. 7.Soiled laundry stored and handled in a manner which does not
3- Personnel preparing food free of infection or illness. contaminate food and food related items and child contact items.
---- o�.roon�rtico D(
1. BATHROOMS
1. Single service items not reused. 1. Cleaned as needed or at least daily.
2. All food equipment and utensils In good repair 2. All required equipment and dispensing fixtures in good repair.
3. Facilities approved after October 31, 1991,have bathrooms
3. Food preparation and storage areas have adequate lighting.
_enclosed with full walls and solid doors:doors closed when not in us
4. Kitchen equipment that produces excessive grease laden 4. Facilities approved after October 31. 1998 mechanically
vapors,moisture or heat properly vented.
ventilated to prevent molds and odors.
5. Facilities shall have mechanical refrigeration for facility use only
Exception: License-E"mpt tacttltles approved prior to October 31,1997 5. Hand
0 shing sinks located in or immediately adjacent to the
bathro
------------
6. No carpeting or absorbent floor coverings in food preparation area. 6. No carpets on floors.
7. Adequate preparation and storage equipment for hot foods
T. Sufficient lighting for Leaning_
8. Facilities with a capacity of 20 children or less shall have: g Storage of bathroom items only.
A Mechanical dishwasher that sanitizes: or employ an additional
sanitizing rinse in conjunction with the mechanical dishwasher, • •
or a 3 compartment sink or a 2 compartment sink with a third 1 If food preparation occurs shall have a sink for food
portable compartment for the final sanitizing step.
preparation seperate from the handwashing sink located
B If a mechanical dishwasher is used,a minimum of two sinks in the diapering area.
=1)hand
in food preparation area designated for.
washing only and 2) food preparation only. 2. Utensils used in the UT Unit washed.rinsed and sanitized after
each use with proper methods and equipment
9. Facilities with a capacity of more than 20 children approved -
before October 31,1991,shall have: X.DIAPERING
EA
A. Mechanical dishwasher that sanitizes; or employ an 1. No utensils washed,rinsed or stored in the diaper changing area.
additional sanitizing rinse in conjunction with a mechanical
dishwasher, or use a three vat sink. 2_ Hand sink with warm running water located in the diapering
area immediately accessible to the diapering surface_
B. It a mechanical dishwasher is used,a minimum of two sinks
located in food preparation area designated for. 3. Diapering surface smooth,easily cleanable,nonabsorbent.and
1)hand washing only and 2) food preparation only. in good repair.
• 4
10.Facilities with a capacity of more than 20 children approved _ Soiled diapers stored in a solid.non absorbent container with
after October 31,1991 shall have: tight fitting lid located in diapering area. -4
5. Soiled diaper container emptied,washed,rinsed and
A. Facility located in providers residence shall have separate food sanitized daily.
preparation and storage areas.
B.A commercial dishwasher or a 3 vat sink in addition to a
LREFUSE DISPOSAL
seperate handwashing sink. 1. Adequate number of containers.
C. If a commercial dishwasher is used,a sink located in food 2 Clean,nonabsorbent,in sound condition.
preparation area designated for food preparation.
3. Outside refuse area clean;containers covered at all times.
• •
�Insmelefuse containers covered when not In use.
1. Catered food from inspected and approved source.
2. Safe food temperature maintained during transport_
Temperature at arrival
3. Facility using catered food exclusively shall have a
hand washing sink.
4. Facility not using single service utensils exclusively meets
applicable dishwashing requirements as stated in Section G8,
or G9,or G10.
•
The above facility has been inspected and [] does LJ does not The inspector has discussed the issues marked by an asterisk
conform with the sanitation requirements of the MO Department of �.)on this form_ I agree to comply with these requirements_
Health,Bureau of Child Care Safety and Licensure. DATe
SIGNATURE OF INSPECTOR TELEPHONE DATSIGNATU
E RE OF CHILD CARE PROVIDER
PIWK/PRnvInFR
Centers, Group Homes and License-Exempt Facilities
Sanitation Inspection Report
DVN:
Facility Name:
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The above facility has been inspected and doesE]does not The inspector has discussed the issues marked by an asterisk
conform with the sanitation requirements of the MO Department of �•�on this form. 1 agree to comply with these requirements.
Health,Bureau of Child Care Safety and Licensure_
SIGNATURE OF INSPECTOR TELEPHONE DATE SIGNATURE OF CHILD CARE PROVIDER
DATE
Df
EXHIBIT E
MISSOURI DEPARTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY AND LICENSURE
VARIANCE REQUEST
• _ • - • '
CAPACITY I AGES SERVED
FACILITY NUMBER
FACILITY TYPE ml1
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License-Exempt. ❑ Religious Organization ❑ Nurse School ❑ Summer Cam ❑ OtherFACILITY PHONE NUMBER
FACILITY NAME
COUNTY
FACILITY ADDRESS
TITLE I POSITION DATE
LICENSEE/DIRECTOR REOUESTING VARIANCE
I am requesting a variance from rule 19 CSR 40-
(Fill in Rule Number Here)
Please explain why you are requesting a variance. Submit any documents.photographs or other information which verifies that the health and safety of children will not
be endangered by approval of this request. (Attach additional sheets as necessary.)
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SNATURE OF CHILD CARE REPRESENTATIVE. THANK YOU!
LICENSEE/DIRECTOR NOTE: PLEASE RETURN COMPLETED FORM 70 YOUR
IG
CONDITIONS OF APPROVAL:
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PROVIDER DISTRICT
RULE NUMBER ❑ NW ONE OC ❑SW ❑ SE D E
❑ LEVELI D LEVELII D LEVEL 111
D FINAL APPROVAL
DATE CHILD CARE REPRESENTATIVE/ENVIRONMENTAL SANITARIAN
D Approved ❑Approved w/conditions ❑ Denied
DATE CHILD CARE SUPERVISOR
LO Approved ❑Approved w/conditions D Denied
DATE DISTRICT CHILD CARE SUPERVISOR
D Approved ❑Approved w/conditions O Denied
DATE DOH CONSULTANT(S)
❑Approved ❑Approved w/conditions D Denied
DATE BUREAU CHIEF
D Approved ❑Approved w/conditions D Deniied za
n. reueav_PROVIDfJt' PINK—SUPERVISOR: GOLDENROD—CENTRAL OFFICE
,* MISSOURI DEPARTMENT OF HEALTH
BUREAU OF CHILD CARE SAFETY AND LICENSURE
.v/ VARIANCE REQUEST / INTEROFFICE COMMUNICATION
FACILITY NUMBER DATE
OFACILITY NAME
• 1:4 • .
CHILD CARE REPRESENTATIVE
CHILD CARE SUPERVISOR
DISTRICT SUPERVISOR
CONSULTATION / EXPERT OPINION
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BUREAU CHIEF
__ _ __ ___...._ ......rc,rnueov_RF(`ORn- vwK—SUPERVISOR; GOLDENROD-C
ENTRAL OFFICE DC 2S
j
EXHIBIT F
BUREAU OF CHILD CARE ENVIRONMENTAL
PUBLIC HEALTH SPECIALIST STAFF
Child Care Sanitation Inspection Contacts
NAME LOCATION
David Bordner, EPHS V Bureau of Child Care Safety and Licensure
573/751-2450 Division of Health Standards and Licensure
Fax 573/526-5345 920 Wlldwood
P.O Box 570
Jefferson City, MO 65102
Bill Smith, EPHS II Central District Health Office
573/751-2891 Child Care Unit
Fax: 573/752-0247 210 El Mercado
Jefferson City, MO 65109
• Jerry Bertoldie, EPHS II Southwestern District Health Office
417/895-6541 Child Care Unit
Fax: 417/895-6994 1414 West Eflindale
P.O. Box 777, MPH
Springfield, MO 65801
Judy Welsh, EPHS II and Northwestern District Health Office
Child Care Unit
Cheryl Murphy, EPHS II 13901 Noland Ct.
816/325-5860 Independence, MO 64055
Fax: 816/325-5878
John Smith, EPHS 11 and Eastern District Health Office
Child Care Unit
Dale Lindberg, EPHS II 220 S. Jefferson, 2nd. Floor
314/877-0210 St. Louis, MO 63103
Fax- 314/877-0203
• Paula Cates, EPHS II Southeastern District Health Office
573/840-9720 Child Care Unit
Fax: 573/840-9727 2875 James Blvd.
Poplar Bluff, MO 63901
:-".:..'..'.4. 0 •
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MISSOURI DEPARTMENT OF HEALTH EXHIBIT G
BUREAU OF CHILD CARE SAFETY AND LICENSURE
REIMBURSEMENT REQUEST FOR CHILD CARE SANITATION INSPECTIONS
BILLING FOR THE MONTH OF MONTHLY TOTAL
LOCAL HEALTH AGENCY $
AUTHORIZED SIGNATURE
ADDRESS
TELEPHONE
CITY,STATE,ZIP
he
hly
Request for
ild
on
The contractor shall assure that all requests and reports he month following the month of inspection,(i en l(therinitted spect inspr to ection completed gIn(May, hetDC- gReimbursementolnth of May must be submitted No later,thanpJune 30)(DC-
3B).
C38). Billings shall be submitted by the last day of t
Reimbursement rates: Initial/Annual-$70; Reins ection-$40; Prea roved Lead inspectionDVN4 NO.r hour Prea roved S ectal Circumstances-$25 per hour.
FACILITY NAME/HOME PROVIDER
FACILITY TYPE
ADDRESS
❑ CENTER ❑ GROUP HOME ❑ FAMILY HOME
CITY,STATE,ZIP ❑ RELIGIOUS ❑ NURSERY SCHOOL ❑ SUMMER CAMP
TYPE OF VISIT DATE OF INSPECTION HOUR:AT ACILITY ADMINISTRATIVE TIME $CHARGE PER VISIT
❑ INITIAL [� REINSPECTION ❑ SPECIAL#1
ANNUAL LEAD SPECIAL#2
TYPE OF VISIT DATE OF INSPECTION HOURS AT FACILITY ADMINISTRATIVE TIME CHARGE PER VISIT
[] INITIAL ❑ REINSPECTION ❑ SPECIAL#1
ANNUAL LEAD SPECIAL#2 TOTAL FACILITY CHARGE
INSPECTOR'S NAME
DVN.NO.
FACILITY NAME/HOME PROVIDER
::JFACILITY TYPE
ADDRESS
El CENTER El GROUP HOME FAMILY HOME
CITY,STATE,ZIP ❑ RELIGIOUS ❑ NURSERY SCHOOL ❑ SUMMER CAMP
=ION
HOURS AT FACILITY ADMINISTRATIVE TIME $HARGE PER VISITTYPE INITISI IIAL ❑ REINSPECTION ❑ SPECIAL#1
ANNUAL LEAD SPECIAL#2HOURS AT FACILITY ADMINISTRATIVE TIME $HARGE PER VISI
TYPE OF VISITINITIAL ❑ REINSPECTION ❑ SPECIAL#1
SPECIAL#2 TOTAL FACILITY CHARGE
ANNUAL LEAD
INSPECTOR'S NAME
Mo 580.2225(7/98) DISTRIBUTION: WHITEIGREENJCANARYIPINK-BCCSL GOLDENROD-LOCAL AGENCY oc-ae•1
•' .
Pago
SAFETY AND LICENSURE f REIMBURSEMENT REQUEST FOR CHILD CARE SANITATION
INSPECTIONS
,uREAU OF CHILD CARE SAF BILLING FOR THE
,OCAL HEALTH AGENCY DVN.NO.
:ACILITY NAME/HOME PROVIDER
FACILITY TYPE ❑ FAMILY HOME
4DDRESS ❑ CENTER ❑ GROUP HOME
❑ ❑
NURSERY SCHOOL ❑ SUMMER CAMP
CITY,STATE,ZIP RELIGIOUS
HOURS AT FACILITY ADMINISTRATIVE TIME CHA
DATE OF INSPECTION RGE PER VIS
TYPE OF VISITC] SPECIAL#1 VE TIME $
❑ INITIAL ❑ REINSPECTION SPECIAL#2
DATE OF INSPECTION HOURS AT FACILITY ADMINISTRATI
ANNUAL
HARGE PER VIS
LEAD
T
YPE OF
INITIAL VISIT
❑ REINSPECTION ❑ SPECIAL#1 70TAL FACILITY CHARGE
❑
❑ Cl SPECIAL#2 $
ANNUAL LEAD
INSPECTOR'S NAME DVN.NO.
FACILITY NAME/HOME PROVIDER
FACILITY TYPE ❑ FAMILY HOME
ADDRESS ❑ CENTER El GROUP HOME
❑ RELIGIOUS ❑ NURSERY SCHOOL ❑ SUMMER CAMP
CITY,STATE,ZIP $
DATE OF INSPECTION HOURS AT FACILITY ADMINISTRATIVE TIME CHARGE PER VISIT
TYPE OF VISIT ❑ SPECIAL#1
REINSPECTION CHARGE PER VISI
❑ INITIAL ❑ SPECIAL#2 $
UAL LEAD DATE OF INSPECTION HOURS AT FACILITY ADMINISTRATIVE TIME
ANN ❑ SPECIAL#1
T❑ INITIAL ❑ $
REINSPECTION TOTAL FACILITY CHARGE
El
ANNUAL SPECIAL#2❑ LEAD
INSPECTOR'S NAME DVN,N0.
FACILITY NAMEIHOME PROVIDER
FACILITY TYPE ❑ FAMILY HOME
❑ CENTER ❑ GROUP HOME
ADDRESS SUMMER CAMP ,
❑ RELIGIOUS ❑ NURSERY SCHOOL ❑
CITY,STATE,ZIP HOURS AT FACILITY ADMINISTRATIVE TIME CHARGE PER VISIT
DATE OF INSPECTION
TYPE OF VISITC] SPECIAL#1
ADMINISTRATIVE TIME C
❑ IT
INITIAL ❑ REINSPECTION SPECIAL#2
DATE OF INSPECTION HOURS AT FACILITY
ANNUALHARGE PER VIS
LEAD
TYPE OF VISIT ❑ SPECIAL#1 TOTAL FACILITY CHARGE
C] INITIAL [] REINSPECTION LEAD
#2 S
CIA NNUAL ❑ LEAD oc-ae•a
IMCDC . nR'S NAME _�,..�eewraNARY/PINK-BCCSL GOLDENROD•LOCAL AGENCY