Form CC81 "Approved Relative Health and Safety Inspection Checklist" - Alaska

What Is Form CC81?

This is a legal form that was released by the Alaska Department of Health and Social Services - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Alaska Department of Health and Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CC81 by clicking the link below or browse more documents and templates provided by the Alaska Department of Health and Social Services.

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Download Form CC81 "Approved Relative Health and Safety Inspection Checklist" - Alaska

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State of Alaska
Department of Health and Social Services
Division of Public Assistance
Child Care Program Office
http://dhss.alaska.gov/dpa/Pages/ccare
Approved Relative Provider
Health and Safety Inspection Checklist
Facility or Family
Date:
Name:
Address:
Phone: (907)
(Street, City, Zip)
Administrator (Person in Charge):
or
Hours of Operation:
In-home Caregiver Name:
Reason for Inspection:
New Application
Annual
Follow up inspection
Special request
Inspection Type:
Announced
Unannounced
Licensing Specialist conducting the Inspection:
CCAP Assigned Worker:
Number of Children Present:
Names of Children Present:
Arrival Time:
Departure Time:
Type of Delivery:
Date Delivered/Sent by Licensing Specialist to CCAP Designee or CCPO:
Hand Delivered
Scan/email
The provider and the child(ren) in care may not reside in the same home. Definitions: Approved Relative Provider: sole caregiver for children all of whom are related to the
provider as grandchild, great grandchild, niece, nephew, or sibling. Care must be provided in the Approved Relative Provider’s private residence.
Key: NR = Not Reviewed
C = Compliance
NC = Noncompliance
D = Discussed
NA = Not Applicable
Description of Regulation
Key
Comments
Admission and Planning for Care 7 AAC 41.207
(a) A provider shall:
(1) Obtain emergency information about the child from the child’s parent, at or
before admission, including
(A) Information about any drug or other allergies
(B) Information about any medication the child is taking or medical or
other treatment the child requires;
(C) Information on how to contact the child’s parent and at least one other
local emergency contact individual;
(D) Permission slips on a form prescribed by the department, signed by
the parent, for emergency transport, care, and treatment; and
CC81 (06-4112) 10/17
Page 1 of 16
State of Alaska
Department of Health and Social Services
Division of Public Assistance
Child Care Program Office
http://dhss.alaska.gov/dpa/Pages/ccare
Approved Relative Provider
Health and Safety Inspection Checklist
Facility or Family
Date:
Name:
Address:
Phone: (907)
(Street, City, Zip)
Administrator (Person in Charge):
or
Hours of Operation:
In-home Caregiver Name:
Reason for Inspection:
New Application
Annual
Follow up inspection
Special request
Inspection Type:
Announced
Unannounced
Licensing Specialist conducting the Inspection:
CCAP Assigned Worker:
Number of Children Present:
Names of Children Present:
Arrival Time:
Departure Time:
Type of Delivery:
Date Delivered/Sent by Licensing Specialist to CCAP Designee or CCPO:
Hand Delivered
Scan/email
The provider and the child(ren) in care may not reside in the same home. Definitions: Approved Relative Provider: sole caregiver for children all of whom are related to the
provider as grandchild, great grandchild, niece, nephew, or sibling. Care must be provided in the Approved Relative Provider’s private residence.
Key: NR = Not Reviewed
C = Compliance
NC = Noncompliance
D = Discussed
NA = Not Applicable
Description of Regulation
Key
Comments
Admission and Planning for Care 7 AAC 41.207
(a) A provider shall:
(1) Obtain emergency information about the child from the child’s parent, at or
before admission, including
(A) Information about any drug or other allergies
(B) Information about any medication the child is taking or medical or
other treatment the child requires;
(C) Information on how to contact the child’s parent and at least one other
local emergency contact individual;
(D) Permission slips on a form prescribed by the department, signed by
the parent, for emergency transport, care, and treatment; and
CC81 (06-4112) 10/17
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(E) The name of a hospital and physician of choice as designated by the
parent
(2) Maintain the information obtained under (1) on a form prescribed by the
department
(3) Review and update information obtained under (1) at least semi-annually,
and more often if a parent provides changed or additional information
(b) A provider may not admit a child if that child’s admission would place the
provider beyond the condition of approval
(c) The provider shall collaborate with the child’s parent in developing and
implementing a plan of care for the child at or before admission when a child is
identified as having special needs or when a special need is identified. The plan of
care
(1) Must be approved by the parent and the provider responsible for the care of
the child and must be signed and dated by the parent and the provider;
(2) Must be based on the following information, to the extent that the parent
consents in writing to disclose the information:
(A) Results of medical and developmental examinations;
(B) Assessments of the child’s cognitive functioning or current overall
functioning;
(C) Evaluations of the family’s needs, concerns, and priorities;
(D)The child’s individualized family service plan (IFSP) developed under
4 AAC 52.142 or individualized education program (IEP) developed under 4 AAC
52.140, if any;
(E)Other evaluations as needed;
(3) Must address any specific services the child care provider will provide in
functional outcome objectives, designated responsibility for provision, and
financing;
(4) Must list any additional services, including educational or therapeutic
services, the child is receiving from other service providers, and must identify the
providers of those services; and
(5) may contain permission from the parent for the child care provider to
contact additional service providers and the child’s IFSP coordinator, if any.
Ratios and Program Requirements 7 AAC 41.211
(b) A provider shall ensure the number of children does not exceed the maximum
of five children, younger than 13 years of age, and no more than two children are
younger than 30 months of age. Each child younger than 13 years of age receiving
care, regardless of the hours in care, must be counted in the maximum number of
children allowed, including the provider’s own children or other children residing
in the provider’s home.
(c) A provider shall provide structure and daily activities designed to promote a
child’s individual physical, social, intellectual, and emotional development. The
provider shall
(1) Provide direct care and supervision of children at all times;
(2) Ensure each child receives responsible supervision that is appropriate to
the child’s age and developmental needs and that is adequate to prevent injury;
CC81 (06-4112) 10/17
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(3) Demonstrate respect for each child in care and the child’s family;
(4) Support behavior of children with positive guidance and set clear and
consistent limits to promote the children’s ability for self-discipline;
(5) Provide children with a variety of age-appropriate learning and social
experiences;
(6) Demonstrate a positive attitude toward bottle weaning, diapering, toilet
learning, and individual needs of children;
(7) Respond appropriately to a child’s needs, including responding to a baby’s
cry as promptly and effectively as possible;
(8) Prevent exposure of children to high risk situations, including exposure to
physical hazards and encounters with individuals or animals posing a possible
danger;
(9) Use strategies to prevent a child’s aggressive behavior and to de-escalate
volatile situations;
(10) Act as a positive role model for children, especially with regard to
respecting the feelings and rights of others;
(11) Provide an environment that respects the gender, culture, ethnicity, family
composition, and special emotional, cognitive, and developmental needs of each
child;
(12) Have a schedule and daily plan of activities for each age group; the
schedule and plan must provide a balance of quiet and active activities, and group
and individual activities, and must include time for meals, snacks, sleep, toileting
according to individual needs, and indoor and outdoor play; for purposes of this
paragraph the schedule and plan need not be written, except that a typical daily
schedule and plan must be presented with the application for approval
(13) Provide opportunities for
(A) Individual self-expression and imaginative play;
(B) At least 20 minutes of vigorous physical activity for every three hours
the provider is open between the hours of 7:00 am and 7:00 pm, and daily
supervised outdoor activity when weather and the individual child’s tolerance
permit;
(C) Each child to foster independence;
(D) Intellectual and social development through use of a variety of
activities and materials such as games, toys, books, crafts, puzzles, and blocks;
(E) Language development, including encouraging children to talk and
read books; and
(14) Limit screen-viewing time, including television, computer, and hand held
devices as follows:
(A) Prohibit screen-viewing time for children under two years of age; and
(B) For children over two years of age, only allow up to one hour of
screen-viewing time in a 24-hour period, except for special occasions, and ensure
(i) Any screen-viewing time shall be for physical or educational use
that is specifically designed for the interest and benefit of the child; and
(ii) Children not be required to participate in screen-viewing
activities. Alternative activities shall be offered as an option for children during
CC81 (06-4112) 10/17
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those times.
(d) A provider caring for infants or toddlers may not routinely leave a child awake
in a crib, swing, or similar device for more than 15 minutes without direct adult
contact. The provider shall
(1) Provide opportunities for a child to develop a caring and nurturing
relationship with and attachment to one caregiver whose care for and
responsiveness to the child ensures relief of distress, experiences of stimulation
and comfort, and satisfaction of the need for a connection with the child’s
caregiver;
(2) Provide frequent verbal communication during feeding, changing, and
cuddle times;
(3) Provide physical contact through holding, rocking, and play, as well as
bathing, dressing, and carrying a child;
(4) Allow infants and toddlers amply supervised opportunity during the day to
explore and learn on their own outside of a play yard or other restraining device;
and
(5) Ensure that infants are placed on their backs to sleep, unless otherwise
ordered by a physician.
(e) A provider caring for school-age children shall provide
(1) A program that supplements rather than duplicates the child’s school
(2) Freedom appropriate to the child’s age and developmental level, and
opportunities for self-reliance and social responsibility; and
(3) Opportunities for school-age children to participate in the selection and
planning of their own activities.
(f) The provider shall treat children in care equitably with the caregiver’s own
children
(g) The provider shall encourage parental involvement and allow parents
unlimited access to their children, provider, and to all areas of the child care
facility, to observe or participate
(h) A provider caring for children identified as having special needs shall
(1) Ensure that the child is afforded opportunities to participate in any
scheduled activities, as possible;
(2) Develop a plan of care under 7 AAC41.207(c) for that child, unless the
provider has reason to believe that, even with reasonable accommodation, the
provider cannot meet the child’s needs and discharges the child;
(3) Implement the plan of care developed under 7 AAC41.207(c) for each
child with special needs to enhance their health and developmental status; and
(4) Conduct regularly scheduled reassessments of each child’s plan of care to
monitor effectiveness.
Behavior Guidance 7 AAC 41.213
(b) A provider shall
(1) Help a child to develop age-appropriate patterns of behavior that foster
constructive relationships and increasing ability to deal with everyday life;
(2) Provide for positive reinforcement, redirection, and the setting of realistic
expectations and clear and consistent limits; and
CC81 (06-4112) 10/17
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(3) Ensure that discipline or a behavior management technique used is not
cruel, humiliating, or otherwise damaging to the child
(c) A provider may not
(1) Remove a child in care from the other children for more than 10 minutes,
except as provided in (d) of this section;
(2) Discipline a child in care in association with food or rest;
(3) Punish a child in care for bedwetting or actions in regard to toileting or
toilet training;
(4) Subject a child in care to discipline administered by another child;
(5) Subject a child in care to verbal abuse, to derogatory remarks about the
child or members of the child’s family, or to treats to expel the child from the
child care;
(6) Place a child in care in a locked room;
(7) Physically restrain a child in care, except when necessary to protect a child
from accident, to protect persons on the premises from physical injury, or to
protect property from serious damage; and then only passive physical restraint
may be used;
(8) Mechanically restrain a child in care, except for a protective device such as
a seatbelt; or
(9) Chemically restrain a child in care, except on the order of a physician and
subject to the provisions of 7 AAC 10.1070
(d) When a child has a pattern of out of control behavior, the child may be
removed from the company of other children until the child’s behavior has
stabilized. In addition, the child care facility shall develop a plan with the child’s
parent to address the behavior issues.
(e) Corporal punishment of children in care is prohibited.
General Health, Medication, and Nutrition Requirements 7 AAC 41.215
(c) A provider shall
(1) Take precautions against the spread of infectious disease by ensuring that
each person in contact with children washes that person’s hands for at least 10
seconds with soap and water and rinses them with water
(A) Before food handling, preparation, serving, eating, or table setting;
(B) After toileting or assisting a child with toileting or diapering;
(C) After handling an animal, animal waste, or an animal cage;
(D) Before and after giving medication;
(E) Before and after participation in moist play, including painting,
cooking, or molding clay; and
(F) If hands are contaminated with a body fluid, including from nose
wiping;
(2) Encourage children to wash their hands at similar times described in (1)
(3) Ensure that children in care have been immunized as required by 7 AAC
57.550(a)-(e), except that children identified as homeless or in protective services
or foster care may be enrolled for up to 30 days without a valid immunization
record
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