Safety / Compliance Form

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Supervision

• 1. Staff-child ratio & group size in compliance, proper supervision. 14-15, 57

  Yes

  No

  N/A

• Director/staff demonstrate good judgement to ensure health and safety of children.

  Yes

  No

  N/A

Licensed capacity

• Facility within licensed capacity.

  Yes

  No

  N/A

Facility

• 2. Free of hazards, hazardous items stored in labeled containers and inaccessible (see 11 (c) (5) in licensing book). 19

  Yes

  No

  N/A

• 3. Facility in good repair, window and door screens, clean and sanitary, free of vermin infestation. 18

  Yes

  No

  N/A

• 4. Temperature between 65 & 80 degrees, adequate lighting, tobacco products prohibited, operable telephone, fire & tornado drills documented. 18

  Yes

  No

  N/A

Fire safety

• 5. Exits not blocked; operable smoke detectors; alarm systems; no portable heaters; tagged fire extinguishers (check dates); no extension cords, outlets covered. 17, 19.

  Yes

  No

  N/A

6. Posted items- to be done on first site visit and first site visit after Christmas break. 4

• License

  Yes

  No

  N/A

• Name of person in charge in director's absence

  Yes

  No

  N/A

• Child abuse reporting notice

  Yes

  No

  N/A

• No smoking notice

  Yes

  No

  N/A

• Emergency procedure

  Yes

  No

  N/A

• Current weekly menu

  Yes

  No

  N/A

• Evacuation plan

  Yes

  No

  N/A

• Emergency numbers and facility address. By each phone in facility.

  Yes

  No

  N/A

• Microwave oven in use sign

  Yes

  No

  N/A

• Welcome sign

  Yes

  No

  N/A

• Monthly fire, tornado, smoke detector (if applicable) us drills, intruder drills dates completed

  Yes

  No

  N/A

• First Aid for dental emergencies posted in each bathroom

  Yes

  No

  N/A

• Exit signs at child level at each exit door - each above door sign lighted

  Yes

  No

  N/A

• Policies and Procedures (sign of availability posted on parent board)

  Yes

  No

  N/A

• Current weekly planning form posted

  Yes

  No

  N/A

• Choctaw Nation Head Start notice to Parents of confidentiality Procedures (parent board)

  Yes

  No

  N/A

• Standard Universal Precautions adhered to and posted by all sink areas

  Yes

  No

  N/A

• First Aid Kits - labeled and in clear site - monthly check dates and initials

  Yes

  No

  N/A

• Bus Route behind Center Supervisors door

  Yes

  No

  N/A

• Stop Disease Method of changing diapers posted by diaper changing station

  Yes

  No

  N/A

• Justice for all Employee rights poster posted available to all staff

  Yes

  No

  N/A

• Disabilities information sign (from NICHCY)

  Yes

  No

  N/A

• DHS notice to parents sign (form 07LC084E) within clear view of Main Entrance

  Yes

  No

  N/A

• Child Welfare Investigation Summary Notification (form 04CP004E) if applicable within clear view of Main Entrance

  Yes

  No

  N/A

• Grant Waiver Notification if applicable

  Yes

  No

  N/A

• Notice where to find DHS Compliance folder if not in view or accessible in parent area

  Yes

  No

  N/A

• DHS transportation information form (07LC005E)

  Yes

  No

  N/A

7. Posted access to records-DHS Compliance file. 4

• Compliance posting and file; accessibility [5(d) & (e)]

  Yes

  No

  N/A

Animals

• 8. Healthy, pose no threat to children; clean areas; current vaccinations. 19-20.

  Yes

  No

  N/A

9. Bathroom(s) 17

• Clean

  Yes

  No

  N/A

• Soap

  Yes

  No

  N/A

• Toilet paper

  Yes

  No

  N/A

• Individual towels

  Yes

  No

  N/A

• Hot and cold or tempered water

  Yes

  No

  N/A

• Operable sinks & toilets

  Yes

  No

  N/A

Equipment

• 10. Required indoor equipment accessible and in a safe sanitary condition. 21

  Yes

  No

  N/A

• 11. Assigned cot or 2" mat; covered by clean bedding; required spacing. 23-24

  Yes

  No

  N/A

• 12. Sturdy diaper changing table with clean moisture proof surface, free of clutter; operable sink with soap and towels, diaper changing procedures posted. 18

  Yes

  No

  N/A

Care of Preschool Children

• 13. Variety of learning areas; weekly lesson plans; tv/videos/smart boards used appropriately. 29-30

  Yes

  No

  N/A

Care of school aged children

• Balance of activities; weekly lesson plans; media used appropriately; guidelines for special activities followed.

  Yes

  No

  N/A

Care of children with disabilities

• Adequate staff; individualized staff instruction

  Yes

  No

  N/A

Water activities

• Parental permission; supervision, for example, staff-child ratios, trained staff or lifeguard, safety rules, approved pools.

  Yes

  No

  N/A

Outdoors

• 14. More than one type of surface; correct depth of impact material fall zone; equipment sturdy, safe, in good repair, anchored, properly spaced; open areas, required outdoor equipment. 29-30

  Yes

  No

  N/A

• 15. Free of hazards adequately fenced; shaded area

  Yes

  No

  N/A

Behavior and guidance

• 16. Constructive and appropriate discipline; children not subject to physical punishment, psychological abuse, etc.

  Yes

  No

  N/A

Health

• 17. Medication properly stored, administered, required first aid supplies (check FA kits) 36-38

  Yes

  No

  N/A

Food & Nutrition

• 18. Meals provide 1/3 of children's daily nutritional requirements, seconds available. 36-38

  Yes

  No

  N/A

• Breakfast or morning snack and afternoon snacks served.

  Yes

  No

  N/A

• Sign regarding microwave safety (child) warning on or by microwave

  Yes

  No

  N/A

• Warning food temperatures

  Yes

  No

  N/A

• kitchen duties

  Yes

  No

  N/A

Food service

• 19. Foods covered; thermometer's in refrigerator and freezer, area clean, neat measures to protect against insects, covered trash container. 42-46

  Yes

  No

  N/A

Transportation

• 20. Appropriate supervision and child-staff ratios. 6 - 3 year olds to one monitor. 39-40

  Yes

  No

  N/A

• 21. Vehicle visibly marked; current insurance; first aid kit & contents; use of car seats and seat belts as required. 39-40

  Yes

  No

  N/A

• 22. Required information in vehicle; written route; attendance checked. 39-40

  Yes

  No

  N/A

• fire extinguisher and first aid kits supplied and checked monthly dated and initialed

  Yes

  No

  N/A

• emergency triangles on board and in tact

  Yes

  No

  N/A

• Bus clean and free of debris

  Yes

  No

  N/A

Records

• Child record card with current immunization record; daily attendance record for each child; permission cards as needed; liability insurance annually.

  Yes

  No

  N/A

Staff

• Staff meet minimum qualifications; appropriate use of staff.

  Yes

  No

  N/A

• Staff meet professional development requirements, such as orientation, entry level training, annual training, first aid.

  Yes

  No

  N/A

• Complete staff information sheet; attendance records; orientation and training documented

  Yes

  No

  N/A

• Documentation of references and criminal background reviews

  Yes

  No

  N/A

• All staff confidential files in locked filing cabinet

  Yes

  No

  N/A

Policy and procedure

• Liability insurance

  Yes

  No

  N/A

• Fire Marshall - Vent - Fire alarm and sprinklers inspection documentation

  Yes

  No

  N/A

Storm Shelters/Safe Rooms

• Emergency Supply

  Yes

  No

  N/A

• Free of insects/animals

  Yes

  No

  N/A

• Clean?

  Yes

  No

  N/A

Additional comments

• Yes

  No

  N/A

Center supervisor comments

• Yes

  No

  N/A

Sign Off

• On site representative

  Sign

• Auditor's signature

  Sign