* = Required Information
IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

Child Name:
Address:
Father's/Guardian's/Father's Domestic Partners Name:
Home Address:
Mother's/Guardian's/Mother's Domestic Partners Name:
Home Address:
Person Responsible for Child:
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ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

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PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

Call Emergency Hospital
Other
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NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACULTY

(Child will not be allowed to leave with any other person without written authorized from parent or authorized representative)

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TO BE COMPLETED BY FACILITY DIRECTORY/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS AND MEDICATION CHART

Note: Regulation Section 101221 requires the following information be on file.

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.

From to at daily while in attendance.

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MEDICATION CHART
Staff Documentation of Medicine Administration

X

X

X

X

X

Upon completion, return medicine to parent or destroy, and place form in child's record.

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 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.

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FAMILY CHILD CARE HOME
NOTIFICATION OF PARENTS' RIGHTS

PARENTS' RIGHTS

As a Parent/Authorized Representative, you have the right to:

  1. Enter and inspect the family child care home 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 family child care home, 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 family child care home without discrimination or retaliation against you or your child.
  5. Be notified and receive, from the licensee, a written notice that lists the name of any person not allowed in the family child care home while children are present. (NOTE: This notice is only required when the Department has, in writing, excluded someone from the family child care home on or after January 1, 2001).
  6. Request in writing that a parent not be allowed to visit your child or take your child from the family child care home, provided you have shown a certified copy of a court order.
  7. Receive from the licensee the name, address and telephone number of the local licensing office.
    • Licensing Office Name:
      Community Care Licensing Division
    • Licensing Office Address:
      750 The city Dr. Suite 250 Orange, CA 92868
    • Licensing Office Telephone #:
      (714)703-2800
  8. Be informed by the licensee, upon request, of the name and type of association to the family childcare home 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.
  9. Receive, from the licensee, the Caregiver Background Check Process form.
  10. Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that covers injury to clients due to the negligence of the licensee or employees of the facility.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILDCARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice "Registered Sex Offender" database, go to www.meganslaw.ca.gov

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ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS

(Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of have received a copy of the "FAMILY CHILD CARE HOME NOTIFICATION OF PARENTS' RIGHTS", the CAREGIVER BACKGROUND CHECK PROCESS and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the licensee.


(Name of Family Child Care Home)

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NOTE: This Acknowledgement must be kept in child's file and a copy of the Notification given to the parent/authorized representative.

For the Department of Justice “Registered Sex Offender” database, go to www.meganslaw.ca.gov

IMPORTANT INFORMATION FOR PARENTS

CAREGIVER BACKGROUND CHECK PROCESS
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

The California Department of Social Services works to protect the safety of children in child care by licensing child care centers and family child care homes. Our highest priority is to be sure that children are in safe and healthy child care settings. California law requires a background check for any adult who owns, lives in, or works in a licensed child care home or center. Each of these adults must submit fingerprints so that a background check can be done to see if they have any history of crime. If we find that a person has been convicted of a crime other than a minor traffic violation or a marijuana-related offense covered by the marijuana reform legislation codified at Health and Safety Code sections 11361.5 and 11361.7, he/she cannot work or live in the licensed child care home or center unless approved by the Department. This approval is called an exemption.

A person convicted of a crime such as murder, rape, torture, kidnapping, crimes of sexual violence or molestation against children cannot by Law be given an exemption that would allow them to own,live in or work in a licensed child care home or center. If the crime was a felony or a serious misdemeanor, the person must leave the facility while the request is being reviewed. If the crime is less serious, he/she may be allowed to remain in the licensed child care home or center while the exemption request is being reviewed.

How the Exemption Request is Reviewed

We request information from police departments, the FBI and the courts about the person's record.We consider the type of crime, how many crimes there were, how long ago the crime happened and whether the person has been honest in what they told us.

The person who needs the exemption must provide information about:

  • The crime
  • What they have done to change their life and obey the law
  • Whether they are working, going to school, or receiving training
  • Whether they have successfully completed a counseling or rehabilitation program

The person also gives us reference letters from people who aren't related to them who know about their history and their life now.

We look at all these things very carefully in making our decision on exemptions. By law this information cannot be shared with the public.

How to Obtain More Information

As a parent or authorized representative of a child in licensed child care, you have the right to ask the licensed child care home or center whether anyone working or living there has an exemption. If you request this information, and there is a person with an exemption, the child care home or center must tell you the person's name and how he or she is involved with the home or center and give you the name, address, and telephone number of the local licensing office. You may also get the person's name by contacting the local licensing office. You may find the address and phone number on our website. The website address is http://ccld.ca.gov/cgntact.htm.

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PARENT NOTIFICATION

ADDITIONAL CHILDREN IN CARE

As required by Health and Safety Code Sections 1597.44(c) and 1597.465(c), you are hereby notified that: (Check one)

I am licensed as a Small Family Child Care Home and may provide care for more than six and up to eight children when one child is enrolled in and attending kindergarten(including transitional kindergarten) or elementary school, and another child is at least sixy ears old, and no more than two infants are in care.

I am licensed as a Large Family Child Care Home, and with an assistant provider, may provide care for more than 12 and up to 14 children when one child is enrolled in and attending kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old, and no more than three infants are in care.

706 W. Lamark Dr., Anaheim, CA 92802

(PRINT FACILITY ADDRESS)

RECEIPT OF PARENT NOTIFICATION (Facility Copy)

Additional Children in Care

I, , acknowledge receipt of the notification that this Small Family Child Care Home may be providing care for more than six and up to eight children, or that this Large Family Child Care Home may be providing care for more than 12 and up to 14 children in accordance with Health and Safety Code Sections 1597.44 and 1597.465.

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Maintain the completed and signed bottom half of this form in the child's record and provide the completed top half of this form to the child's parent or authorized representative.

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NEBULIZER CARE CONSENT/VERIFICATION

CHILD CARE FACILITIES

This form may be used to show compliance with Health and Safety Code Section 1596.798 before a child care licensee or staff person administers inhaled medication to a child in care. A copy of the completed form should be filed in the child's record and in the personnel file. A separate form must be filled out for each person who administers inhaled medication to the child.

I, , give my consent for Edith Gates/Happy Hearts Preschool Child Care, who work(s) at 706 W. Lamark Dr., Anaheim, CA 92802, to administer inhaled medication to my child, and to contact my child's health care provider.

In addition, I certify that I have personally instructed the above-named licensee or staff person on how to administer inhaled medication to my child.

I have also provided the Child care facility with written instructions from my child's physician, or from a health care provider working under the supervision of my child's physician (for example, a physician's assistant, nurse practitioner or registered nurse). These instructions include:

  • Specific indications (such as symptoms) for administering the inhaled medication in accordance with the physician's prescription.
  • Potential side effects and expected response.
  • Dose form and amount to be administered in accordance with the physician's prescription.
  • Actions to be taken in the event of side effects or incomplete treatment response in accordance with the physician's prescription. This includes actions to be taken in an emergency.
  • Instructions for proper storage of the medication.
  • The telephone number and address of the child's physician.
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FAMILY CHILD CARE
CONSUMER AWARENESS INFORMATION

Family Child Care (FCC) is provided by the home of a licensed provider for up to eight children with one adult or up to 14 children with one adult and one assistant. FCC homes provide a home like setting. Making sure the the licensed FCC homes are providing safe care is the job of the licensing agency, the parents and the provider.

HEALTH and SAFETY
CHECKLIST

You should check for basic health and safet practices in the home. You FCC Provider, by state law and regulation, must do the following:

  • Get a license from the local licensing agency.
  • Provide care to no more than eight children (with no more than two children under age 2) or 14 children with an assistant (with no more than 3 children under age 2).
  • Make sure the home has heat in cold weather and is cool in hot weather.
  • Keep detergents and cleaning products out of children's reach.
  • Make sure swimming pools are fenced or have a pool cover
  • Baby gates must block stairs in facilities when children less thank five years old are in care.
  • Store guns, other weapons, and poisons in locked areas.
  • Have an emergency plan in case of fire or earthquake.
  • Keep a fire extinguisher and working smoke alarm in the FCC home.
  • Provide a smoke free environment.
  • Not use a baby walkers, bouncers or similar items

WHAT SHOULD THE FAMILY CHILD CARE HOME PROVIDE?

You should get answears to these questions before placing you child in the home:

  • Is the home clean and safe?
  • Are there enough toys and games
  • How will my child be disciplined? (Spanking, hitting, slapping, shaking, and so forth are no permitted in licensed homes.)
  • What meals will my child be given?
  • How will the food I bring be stored and preared?
  • Is there enough room (indoor and outdoor) for my child to play?
  • What activities are planned for my child?
  • How will my child be cared for when he or she gets sick?
  • How many other children will be in care?
  • What ages are the other children?
  • What are the sleeping/napping/rest arrangements?
  • How will I find out if my child is hurt or injured while in care?

DISCUSS THE FOLLOWING WITH THE PROVIDER:

  • Setting times for arrival ad pickup.
  • Bringing items from home (food, toys, change of diapers, change of clothes, toothbrush, infant furniture, and so forth)
  • Providing instructions for giving medicines or special food.
  • Providing telephone numbersf or home, work, spouse's work, doctor and neighbor.
  • Proving a list of names and telephone numbers of people who may pick up your child.

GOOD CHILD CARE INCLUDES THESE THINGS:

  • A Provider who provides warm and loving care and guidance for you child, and who works with you and your family to make sure your child grows and learns in the best way possible.
  • A home that keeps your child safe, secure, and healthy.
  • Acitivites that help your child grow mentally, physically, socially and emotionally
  • Your Environment in your child's care.
WHAT ARE PARENTS'
RESPONSIBILITIES?

The California Department of Social Services licenses home to provide child care, and wants you to understand the licensing laws and the ways in which you can check the quality of care you child receives.

WHAT SHOULD PARENTS DO?

  • Ask to see the FCC home licence. Homes caring for children from more than one family must be licensed.
  • Check the condition of the FCC home frequently. Parents have the legal right to "drop in" at any time care is being provided.
  • Know your rights as a parent by reading and keeping the Notification of Parents' Rights form.
  • Make sure the Parent's Rights Poster is displayed in the home.
  • Watch how your child acts in the home.
  • Listen to what you child tells you about the care received in the home.
  • Talk with the provider about any problems. Inform the provider of anything in the home which could hurt your child.
  • Call or write the licensing agency if the provider fails to fix a hazard or if you believe you child has been harmed while in the provider's care. (See "How to file a complaint")
  • Ask to see the licensing reports on file in the home.
  • Call or visit the licensing office and ask to look at you provider's licensing file,
  • Ask if there are any adults in the home that have a criminal background.

PARENTS OF BABIES SHOULD ENSURE THAT:

  • The baby receives good nutrition and is fed at the proper times
  • A stimulating environment is provided.
  • The provider gives emotional support, and holds the child regularly.
  • The provider cares for no more than four babies.
  • Babies are placed on their backs when put down to sleep or nap.

HOW TO FILE A COMPLAINT ABOUT A FAMILY CHILD CARE HOME

COMPLAINT PROCESS

  1. If you thing a FCC profider is breadking the licensing laws, you may file a complaint with the local licensing offic. You can find the address and telephone number in the following ways:
    • the provider's license
    • your copy of the Parent's Rights Notifications form
    • the telephone book under:
      STATE OF CALIFORNIA
      DEPARTMENT OF SOCIAL SERVICES
      COMMUNITY CARE LICENSING
      OR
      COUNTY OF ORANGE
      WELFACE OR SOCIAL SERVICES DEPARTMENT
      CHILD CARE LICENSING
    • The California Deparment of Social Services Community Care Licensing Division's website at www.ccld.ca.gov
  2. Call or write your local licensing office and explain you complaint. Your name will remain anonymous unless you give us permission to use it. You will be notified of the results when the investifgation is done.
  3. If you believe your child is being physically or sexually abused, you should also report it you your local Police Department of Sheriff's Department.
  4. Contact the local licensing office about any issues or questions you may have.
  5. To learn more about the CHild Care LIcensing program and services, lease visit our website. There you will find child care licensing updates, regulations, and information about the child care advocate program.

WHEN YOU REPORT SUSPECTED VIOLATIONS YOU NOT ONLY PROTECT YOUR CHILD BUT ALSO PERFORM A SERVICE TO YOUR COMMUNITY.

WHAT THE LICENSING AGENCY DOES

  • Visits each FCC home before issuing a license to operate.
  • Does criminal background checks and child abuse index checks on all adults in the home.
  • Required tuberculosis (TB) tests of providers
  • Investigate complaints.
  • Makes unannounce visites to the FCC home.
  • Denies applications and revokes licenses when necessary.