Fillable MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT CHILDRENS RECORDS MODULE (California)

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MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT CHILDRENS RECORDS MODULE (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT
CHILDREN’S RECORDS MODULE
CHILD CARE CENTERS
This guide is provided to child care centers determined by the licensing agency as eligible for a modified
comprehensive visit. For eligible centers, the licensing evaluator will not include a review of children’s records as
part of the annual licensing evaluation. The licensing evaluator will, however, review children’s records at least one
time during a three-year period. When given this guide, the child care center will be asked to evaluate children’s
records requirements independently, and to certify that all records are in compliance with licensing standards. This
independent review is voluntary. If the child care center chooses to review these records, review by the licensing
evaluator will not be necessary.
This guide is to assist child care centers in reviewing the records for the children in care. The guide lists some of
the most common problem areas in
volving children’s records found by licensing staff. Read each statement and
check Met or Not Met for the answer that best describes the completeness and accuracy of the records in the
center. If a problem with children’s records is identified (records are missing, incomplete, or inaccurate), please
take appropriate action to ensure that the problem is corrected within 30 days. This is not a complete list of
licensing requirements. When the licensing worker visits, they may look at more than what is in this guide. Please
review the child care center regulations for all requirements.
Met Not
Met
Children’s Records
1. Children’s records are current and kept confidential. [101221]
- Records are updated when needed.
- Kept for 3 years upon termination of services.
2. Admission Agreements [101219, 101221].
3. Immunizations are current.
- Immunizations are current (‘blue cards’; PM 286) for non-school-age children [101220.1].
- No child was admitted without proof of up-to-date immunizations.
- Against belief statement on file.
4. Authorizations for dispensing medications signed by parents [101221].
5. Identification and emergency information forms (LIC 700) [101221].
6. Medical assessment is on file [101220].
- Child’s Pre-Admission Health History-Parent’s Report Forms (LIC 702).
- Child’s Pre-Admission Health Evaluations-Physician’s Report forms (LIC 701).
- Special needs identified.
- Medication needs included.
- Ambulatory status included.
LIC 9199 (7/01)
Page 1 of 2
7. Documentation required for health-related services (e.g., blood-glucose. monitoring,
nebulizer care (LIC 9166), gastrostomy-tube care (LIC 701A and LIC 701B).
8. Consent for Emergency Medical Treatment forms (LIC 627)
[101221, 101226].
9. Needs and Services Plans for infants, if applicable [101419.2].
10. Unusual behavior or signs of illness is reported to the parent/guardian and
noted in the child’s record [101226.3].
- Unusual Incident/Injury or Death Reports (LIC 624).
11. Parents’ Rights (LIC 995) receipts, signed and dated [101218.1, 101221].
12. Personal Rights (LIC 613) receipts, signed and dated [101221, 101223].
Notes/Comments
Please complete the self-certification statement after review of the center’s children’s records. Attach the Facility Evaluation
Repor
t (LIC 809) to this document and keep the completed and signed form in the f
acility file available for public review. At
the time of the next visit by the licensing evaluator, he/she may ask to see this completed form.
I certify, under penalty of perjury under the laws of the State of California, that the above is true and correct. I understand that
I am responsible for correcting all deficiencies.
SIGNATURE OF LICENSEE/FACILITY REPRESENTATIVE DATE
FACILITY NAME FACILITY NUMBER EVALUATOR
Page 2 of 2
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MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT CHILDRENS RECORDS MODULE (California)

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Completed 15 January 2022

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