Fillable Lic9217 LIC 9217.pdf

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Lic9217 LIC 9217.pdf

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PRE-LICENSING READINESS GUIDE - FAMILY CHILD CARE HOME
Before you receive a Family Child Care Home license, the licensing agency will visit your home to
make sure that your home meets licensing requirements. Below is a checklist of requirements to help
you get ready for our visit. As each requirement is completed, please put a check mark next to it.
When your home has met all of the requirements:
• SIGN AND DATE THE FORM AT THE BOTTOM.
• MAIL THIS FORM BACK TO THE LICENSING AGENCY (When the licensing agency
receives this form, it will mean that your home meets all of the requirements and you
are ready for your visit.)
• A LICENSING PROGRAM ANALYST WILL CALL YOU TO SET UP A DATE FOR OUR VISIT
TO YOUR HOME.
THE FOLLOWING ITEMS ARE REQUIRED BY REGULATION
■ All adults living in the home and assistant and/or substitute care providers have submitted fin-
gerprints and child abuse index check forms to Department of Justice and received a
California clearance or exemption.
■ Home is neat and clean.
■ All fireplaces, woodstoves, and/or heaters are screened to prevent access by children.
■ Home has a fully charged fire extinguisher which is at least a 2A:10BC.
■ Home has a working smoke alarm.
■ Home has a working telephone.
■ All poisons are locked.
■ Hazardous materials are kept out of the reach of children (inaccessible):
■ Kitchen: all sharp utensils and cutlery, cleaning supplies, medicines,
drawers and cabinet
s with liquor, plastic bags, and sharp things or small things children
can swallow, etc.
■ Bathroom: shampoo, mouthwash, toothpaste, medicines,
perfumes/lotions/cosmetics, solvents, etc.
■ Garage and Outdoors: solvents, gasoline, oil, turpentine, paint, sharp tools, lawn
mower, gardening tools, poisonous plants, abandoned machinery, old
refrigerators/freezers, old vehicles, etc.
■ All firearms and any other weapons are not loaded and are locked up. Ammunition is stored
and locked away separately from firearms.
■ Outdoor play area is free from defects or dangerous conditions. Play equipment is securely
anchored according to manufacturer directions.
LIC 9217 (3/05)
Page 1 of 2
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Outdoor play area is fenced.
-or-
Outdoor play area is not fenced and the plan for supervision is:
■ If caring for children under 5 years old, home has a gate(s) blocking the stairs.
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Home does not have a swimming pool, spa, hot tub, fishpond, or any other bodies of water.
-or-
Home does have a _______________________________________, covered or fenced.
(Write in type of body of water)
The fence is at least 5 feet feet high with a self-latching gate that opens away from the pool
or body of water. If using a cover, it must support the weight of an adult and shall be locked
when pool is not in use.
■ Toys and playthings are safe, clean, and appropriate for the age of the children.
■ Babywalkers, bouncers, jumpers, and similar items will not be used for children in care and
are kept inaccessible.
■ A copy of the deed or property tax statement, or if renting or leasing, a copy of the lease or
rental agreement is available at the home.
THERE
ARE MANY OTHER THINGS YOU CAN DO TO MAKE YOUR HOME SAFE THAT
MAY
NOT BE IN REGULATIONS. IF YOU HAVE ANY QUESTIONS, CALL YOUR LICENSING
PROGRAM ANALYST.
ADDITIONAL NOTES:
My home meets all of the above requirements and I am ready for a pre-licensing
inspection.
SIGNATURE
DATE
PRINT YOUR FULL NAME
Keep a copy of this form and use the area below to note the date and time we will visit your
home and the name and telephone number of your Licensing Program Analyst.
DATE FOR MY HOME VISIT:
TIME OF HOME VISIT:
NAME OF MY LICENSING PROGRAM ANALYST:
TELEPHONE #
LIC 9217 (3/05)
Page 2 of 2
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Completed 22 June 2020

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