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MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT STAFF QUALIFICATIONS/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
STAFF QUALIFICATIONS/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 staff records as part of
the annual licensing evaluation. The licensing evaluator will, however, review staff records at least one time during
a three-year period. When given this guide, the child care center will be asked to evaluate staff 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 in reviewing staff records in the child care center. The guide lists some of the most common
problem areas involving staff records found by licensing staff. Read each statement and check Met or Not Met f
or
the answer that best describes the completeness and accuracy of the records in the center. If a problem with staff
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
Staff Qualifications/Records Requirements
1.
Center has a director [101215/101215.1]
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Administrative responsibility statement on file.
Director or substitute is on site at all times.
2.
Director is qualified.
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Qualifications submitted to licensing (Evaluation of Director Qualifications, form LIC 9096)
[101215], [101215.1], [101415], [101515], [101615].
Fingerprint (CII, FBI) cleared or exemption, if needed, obtained.
[101170].
Criminal record statements (LIC 508) [101170(c), 101216(l)].
Child Abuse Index Check obtained, if not on LIC 555.
Health clearance on file, including TB clearance (may be on LIC 503)
[101216, 101217].
3.
Teachers are qualified.
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Qualifications on file
, including staff qualification sheets (Ev
aluation of
Teacher Qualifications,
form LIC 9095) for all 12-unit teachers with attached transcripts [101216.1, 101416.2,
101516.2].
Reference letters verifying work experience on file [101216.1],
[101416.2], [101516.2], [101616.2], [101616.3].
Proof of enrollment in ECE/CD courses on file.
Fingerprint (CII, FBI) clearances or record of submission or exemption, if needed, obtained.
[101170].
Criminal record statements (LIC 508) [101170(c), 101216(l)].
Child Abuse Index Check obtained if not on LIC 555.
Health clearance on file, including TB clearance (may be on LIC 503)
LIC 9198 (7/01)
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4. Teacher Aides are qualified [101216/101216.1/101416.2].
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18 years of age, high school graduate, in accredited ROP program.
Works under direct supervision of teacher.
Fingerprint (CII, FBI) clearances or record of submission or exemption,
if needed, obtained [101170].
Criminal record statements {LIC 508) [101170(c), 101216(l)].
Child Abuse Index Check obtained if not on LIC 555.
Health clearance on file, including TB clearance (may be on LIC 503)
[101216, 101217].
5. Personnel Record (LIC 501) or application/resume with required information
[101217].
6. Notice of Employee Rights receipts (LIC 9052) [101216, 101217].
7. Pediatric CPR/first aid cards for designated staff. At least one director or teacher
must have full 15 hours of health and safety training [101215.1(m), 101216].
8. Volunteers are supervised by a teacher [101216].
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Not included in staffing plan/ratio.
Health statement signed and on file.
Negative TB test on file.
9. Personnel records are complete and available for review [101217].
Records are kept for 3 years.
10. Duties of staff and volunteers are in writing and available for review
[101217].
11. Copy of driver’s license for staff transporting children [101217].
12. Statement Acknowledging Requirement to Report Suspected Child Abuse
(LIC 9108).
Notes/Comments (If additional space needed, attach page to this document)
Please complete the self-certification statement after review of the center’s staff records. Attach the Facility Evaluation Report
(LIC 809) to this document and keep the completed and signed form in the facility file available for public revie
w. 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
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MODIFIED COMPREHENSIVE VISIT LICENSEE SELF-ASSESSMENT STAFF QUALIFICATIONSRECORDS MODULE (California)

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Completed 15 January 2022

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