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PERSONAL RIGHTS Child Care Centers Personal Rights, See (Albany High School)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her
needs.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily
living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to
physical functioning.
(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the
provisions of law regarding complaints including, but not limited to, the address and telephone number of the
complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor
of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely
voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from
spiritual advisors shall be made by the parent(s), or guardian(s) of the child.
(6) Not to be locked in any room, building, or facility premises by day or night.
(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
NAME
(PRINT THE NAME OF THE FACILITY)
(PRINT THE NAME OF THE CHILD)
(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)
LIC 613A (8/08)
(PRINT THE ADDRESS OF THE FACILITY)
ADDRESS
CITY ZIP CODE AREA CODE/TELEPHONE NUMBER
DETACH HERE
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the
California Code of Regulations, Title 22, at the time of admission to:
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHILD CARE CENTER
NOTIFICATION OF PARENTS’ RIGHTS
PARENTS’ RIGHTS
As a Parent/Authorized Representative, you have the right to:
1. Enter and inspect the child care center without advance notice whenever children are in care.
2. File a complaint against the licensee with the licensing office and review the licensee’s public file
kept by the licensing office.
3. Review, at the child care center, reports of licensing visits and substantiated complaints against the
licensee made during the last three years.
4. Complain to the licensing office and inspect the child care center without discrimination or retaliation
against you or your child.
5. Request in writing that a parent not be allowed to visit your child or take your child from the child
care center, provided you have shown a certified copy of a court order.
6. Receive from the licensee the name, address and telephone number of the local licensing office.
Licensing Office Name: _________________________________________________
Licensing Office Address: _________________________________________________
Licensing Office Telephone #: _________________________________________________
7. Be informed by the licensee, upon request, of the name and type of association to the child care
center for any adult who has been granted a criminal record exemption, and that the name of the
person may also be obtained by contacting the local licensing office.
8. Receive, from the licensee, the Caregiver Background Check Process form
.
NOTE: C
ALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A
PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE
POSES A RISK TO CHILDREN IN CARE.
LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS’ RIGHTS
(Parent/Authorized Representative Signature Required)
I, the parent/authorized representative of ________________________________________________, have
received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the
CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
_____________________________________
Name of Child Care Center
______________________________________________ __________________
Signature (Parent/Authorized Representative) Date
NOTE:
This Acknowledgement must be kept in child’s file and a copy of the Notification given to
parent/authorized representative.
LIC 995 (9/08)
For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov
For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
IDENTIFICATION AND EMERGENCY INFORMATION
CHILD CARE CENTERS/FAMILY CHILD CARE HOMES
To Be Completed by Parent or Authorized Representative
CHILD’S NAME LAST MIDDLE FIRST
ADDRESS NUMBER STREET CITY STATE ZIP
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST
HOME ADDRESS NUMBER STREET CITY STATE ZIP
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST
HOME ADDRESS NUMBER STREET CITY STATE ZIP
PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST
PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER
DENTIST ADDRESS MEDICAL PLAN AND NUMBER
TIME CHILD WILL BE CALLED FOR
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE
DATE OF ADMISSION
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
■■ CALL EMERGENCY HOSPITAL ■■ OTHER EXPLAIN: ____________________________________________________________________________________________________________________
NAME
NAME
ADDRESS TELEPHONE RELATIONSHIP
RELATIONSHIP
SEX
HOME TELEPHONE
( )
TELEPHONE
( )
TELEPHONE
( )
TELEPHONE
( )
DATE
DATE LEFT
BIRTHDATE
BUSINESS TELEPHONE
( )
BUSINESS TELEPHONE
( )
BUSINESS TELEPHONE
( )
HOME TELEPHONE
( )
HOME TELEPHONE
( )
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
LIC 700 (8/08)(CONFIDENTIAL)
DAILY ROUTINES (*
For infants and preschool-age children only
)
DEVELOPMENTAL HISTORY (
*
For infants and preschool-age children only
)
STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CHILD’S NAME SEX BIRTH DATE
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
BEGAN TALKING AT
*
MONTHS
TOILET TRAINING STARTED AT
*
MONTHS
WALKED AT
*
MONTHS
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT COLDS?
■■ YES ■■ NO
WHAT TIME DOES CHILD GET UP?
*
DOES CHILD SLEEP DURING THE DAY?
*
DIET PATTERN:
(What does child usually
eat for these meals?)
ANY FOOD DISLIKES?
WORD USED FOR “BOWEL MOVEMENT”
*
PARENT’S EVALUATION OF CHILD’S HEALTH
PARENT’S EVALUATION OF CHILD’S PERSONALITY
HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
PARENT’S SIGNATURE DATE
LIC 702 (8/08) (CONFIDENTIAL)
WORD USED FOR URINATION
*
IS CHILD TOILET TRAINED?
*
■■ YES ■■ NO
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
■■
YES
■■
NO
IF YES, NAME OF DOCTOR:
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
■■ YES ■■ NO
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
IF YES, AT WHAT STAGE:
*
ARE BOWEL MOVEMENTS REGULAR?*
■■ YES ■■ NO
ANY EATING PROBLEMS?
WHAT IS USUAL TIME?
*
BREAKFAST
LUNCH
DINNER
WHEN?
*
HOW LONG?
*
WHAT ARE USUAL EATING HOURS?
BREAKFAST ________________________
LUNCH_____________________________
DINNER
WHAT TIME DOES CHILD GO TO BED?
*
DOES CHILD SLEEP WELL?
*
HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
■■ Chicken Pox
■■ Asthma
■■ Rheumatic Fever
■■ Hay Fever
■■ Diabetes
■■ Epilepsy
■■ Whooping cough
■■ Mumps
■■ Poliomyelitis
■■ Ten-Day Measles
(Rubeola)
■■ Three-Day Measles
(Rubella)
DATES DATES
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
DOES CHILD USE ANY SPECIAL DEVICE(S):
■■
YES
■■
NO
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?
■■
YES
■■
NO
IF YES, WHAT KIND:
IF YES, WHAT KIND:
( )( )
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER
NAME
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.
DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
HOME ADDRESS
HOME PHONE
LIC 627 (9/08) (CONFIDENTIAL)
WORK PHONE
I authorize child care personnel to assist in the administration of medications described above to the child named
above for the following medical condition/s:
From ____________________ to __________________ at ___________________ daily while in attendance.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS AND MEDICATION CHART
NOTE: Regulation Section 101221 requires the following information be on file.
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHILD CARE CENTER NAME:
CHILD’S NAME
MEDICATION NAME
DATE OF BIRTH
DOSAGE
BEGINNING DATE
PARENT’S SIGNATURE:
DATE
DATE
DATE
DATE
DATE
DATE
STAFF
LIC 9221 (8/08)
TIME GIVEN
TIME GIVEN
TIME GIVEN
TIME GIVEN
TIME GIVEN
STAFF SIGNATURE
STAFF SIGNATURE
STAFF SIGNATURE
STAFF SIGNATURE
STAFF SIGNATURE
DATE:
ENDING DATE TIME OF DAY
PARENT’S INSTRUCTIONS:
1. All prescription and nonprescription medications shall be maintained with the child’s name and shall be dated.
2. Prescription and nonprescription medications must be stored in the original bottle with unaltered label. Medications
requiring refrigeration must be properly stored.
3. Prescription and nonprescription medication shall be administered in accordance with the label directions.
4. Written consent must be provided from the parent, permitting child care facility personnel to administer medications
to the child. Instructions shall not conflict with the prescription label or product label directions.
LICENSE NUMBER: DATE:
MEDICATION CHART
Staff Documentation of Medicine Administration
Upon completion, return medicine to parent or destroy, and place form in child’s record.
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PERSONAL RIGHTS Child Care Centers Personal Rights, See (Albany High School)

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Completed 16 March 2022

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