1. Purchase and familiarize yourself with the regulations. Download the Level of Care Standards Manual from the Internet.
2. Purchase Licensure Application Package for $12.00.
3. Submit Applications with floor plans, site plans, and a description of the services you plan to provide to ORS. Contact the Provider Support Unit to indicate your interest in contracting with the State as an Approved Provider.
4. Receive approval from ORS of plans.
5. Submit approved plans to the required local and state agencies. (Fire, Building, Health Department and Zoning if applicable).
6. Submit operation plans to ORS.
7. Prepare facility / agency for compliance with Regulations.
8. Conduct Self-Study for preparation of your compliance with Regulations.
9. Obtain verification of approvals from other governmental agencies listed in #5.
10. Submit a statement of your readiness for opening to ORS with attached other approvals in #9.
11. ORS will schedule an inspection at the site of the facility / agency.
12. Participate in the on-site evaluation.
13. Receive permission to operate from ORS and BEGIN OPERATION.
14. Contact the Provider Support Unit to begin Approved
Name of Organization: Phone Number:
Street City Zip Code Country P.O. Box
Under the provisions of the Official Code of Georgia, Chapter49-5, application is hereby
made for a license to conduct the following child welfare program:
Signature-President of Governing Body
|Name of Officers and Governing Board||Title of Office||Address|
(Attach notarized letter of acceptance for those who do not have letter on file with the department)
Name of Person Designated to Work with Licensing Consultant
Director is defines as the chief administrative or executive officer of a facility.
Employee is defined as any person, other than a director, employed by a center to perform at any of the center's facilities any duties which involve personal contact between that person and any child being cared for at the facility and also includes and adult person who resides at the facility or who, with or without compensation, performs duties for the center which involve personal contact between that person and any child being cared for by the center.
1. Who must be fingerprinted?
b. Person regularly in charge in absence of director.
c. An employee who is promoted to director
e. Any director of a currently licensed center who becomes director of another center, whose CRC was processed more than 12 months earlier. If CRC was processed less than 12 months earlier, a copy is to be submitted for verification.
f. Owner's who actively participate in day-to-day operations.
g. Any employee where fingerprints may be needed to confirm
identification. These will be requested by the Special Services Section.
b. Volunteers who have contact with children.
c. Auxiliary staff who have contact with children.
d. Owners, other than directors, who don't actively participate
in operation but
have contact with children.
e. Any other adult who resides in a family day care home
who may have contact
with children in care.
A criminal records check must be completed for all persons working in childcare facilities in Georgia. The background check process may consist of either one part, Records Check Application, or two parts, Record Check Application and Finger print Cards, depending upon employment status. Child care workers who are simply employees must complete only one part of the process (Part I). Directors of child care facilities, family day care providers, and foster parents used by child caring institutions must complete the two-part process (Part I and Part II).
(Instructions on the back Form 5579)
2. The signature of the applicant must be notarized.
3. A processing fee of $3 per application payable by check or money order to the Georgia Department of Human Resources must accompany the records check application form(s). CASH IS NOT ACCEPTABLE.
4. Application(s) and processing fee(s) must be mailed to the address below.
1. Both cards must be completed with the following information:
b. Employer's name and address (box above "reason fingerprinted")
c. Social security number
d. Race, height, weight, hair and eye color. Abbreviations for hair/eye color: HAIR: blk-black; BRN- brown; GRN-green; GRY-gray; BLU-blue
e. Date of Birth
f. Applicant's signature must be on both cards.
2. Fingerprints must be taken by local law enforcement official.
3. Both fingerprint cards must be signed and dated by the official taking the prints. Prints must be clean and properly rolled. Prints should not be smudged, too dark or too light. Improper fingerprints will be returned to be taken again.
4. A $24.00 MONEY ORDER ONLY made payable to the Georgia Bureau of Investigation must be remitted.
5. Applicants must send two fingerprint cards and a records check application with the proper payment to:
To order more criminal records check (CRC0 applications and/or more fingerprint cards (FPCs), please complete the following and mail to:
2 Peachtree Street, 21st Floor
Atlanta, GA 3030-3167
Number of CRC Forms_________
Number of FPCs _________
2. Submit copies of forms and/or documentation to show compliance with each item listed below and this checklist to Child Care Licensing. This copy will be kept for the Child Care Licensing Files. Keep one copy for your files.
3. Submit a self-addressed, stamped envelope sufficient in size with adequate postage to receive your copy of the evaluated checklist.
4. All items listed below should be represented on the operation plan or answered on the checklist which is attached to your plan. Child Care Licensing Unit will use this checklist to evaluate your plan using the following key: C = Compliance; NC = Noncompliance, insufficient information; NA = Not Applicable. CCI =Rules and Regulations for Child-Caring Institutions.
5. Submit copies of all sample forms used by the agency.
NOTE: If using a sample form supplied by the Department, indicate this on your checklist.
290-2-5-.04 Governing Body
Submit a copy of bylaws for governing body
290-2-5-.05 Licenses and exemptions
Submit copy of incorporation documents if applicable.
290-2-5-.08 (5) (d) 1-10
|__ Identifying Information
___ Education/qualifying work experience
___ Criminal record status
___ Job description
|___ Employment history
___ Date of employment
290-2-5-.08 (6) (d) (i-viii) and 2.
1. Orientation (Staff Training)
B. Submit copy of form used to document orientation.
C. Submit a written plan for annual staff development to include the 24 clock hour of annual training, biennial renewal of CPR and triennial renewal of first aid.
290-2-5-.09 Referral and Admissions
290-2-5-.09 (2) (a) Submit written admission policies and procedures (statement of criteria)
290-2-5-.10 Assessment and Planning
2. Submit a sample plan of care.
290-2-5-.11 Discharge and Aftercare
Submit Policies and Procedures regarding Discharge and Aftercare.
290-2-5-.12 Child Care Services
Submit a copy of written agreement with physician, dentist, and hospital who will treat residents.
290-2-5-.13 Foster Home Care
Submit Policies and Procedures regarding foster care services if applicable.
290-2-5-.14 Discipline and Behavior Management
Submit Policies and Procedures on Discipline and Behavior Management.
290-2-5-.17 Food Service
Submit at least a one month's sample menu which meets nutritional guidelines.
290-2-5-.18 Physical Plant and Safety
1. Institution complies with local Building Codes
__plumbing __electrical __housing __fire
Attach copies of approvals of appropriate authorities.
2. Submit a copy of the zoning approval.
3. Submit a drawing of the grounds indicating __ size
__ location of building on lot with proper identification of each building.
__ location of any outdoor recreational areas;
__ swimming pool if applicable
4. Water Supply Source: Indicate the method used to provide water. Submit approvals of private systems from the Department of Natural Resources.
5. Sewage System: Indicate the type of sewage system used. If private system, submit approval from Health Department.
6. Submit Documentation that each bedroom provides a minimum of 63 square feet of space per resident and at least 75 square feet for individual bedrooms.
7. Document the number of lavatories, showers, and mirrors.
8. Indicate the availability of three compartment sinks or two compartment sinks and dishwasher with hygienic or sani-rinse cycle.
9. Transportation Records. Documentation of Insurance.
Inspection on condition of vehicle (annual inspection - Form # 699 or its
equivalent. Documentation of licensed driver for the class of the vehicle.
Documentation of manufacturer's rated seating capacity.
NOTE: If the vehicle has not been obtained and the licensed driver has not been designated at the time you submit the Operations Plan, you may submit the items starred above with Part B - Application for License.
( ) PLAN APPROVED
( ) PLAN NOT APPROVED - ADDERSS ALL ITEMS MARKED NC OR ? AND REURN REVISED PLAN WITH THIS CHECKLIST AND A STAMPED, SELF-ADDRESSED ENVELOPE.
Reviewed by:_______________________ Date:___________________
COMPLETE THE TOP PORTION OF THIS FORM WITH BLACK INK AND ATTACH TO ROOM PLANS
( ) CCI
(Name of applicant)
(Street or P.O. Box Address
(City, State, Zip Code)
(Telephone numbers) _________________________
(Date attended Office Conference)
(Name of proposed program) )
(Facility Address St. or Route)
(City) (Zip Code)
(Telephone numbers) (County)
(Ages of Children) (Hrs of Operation)
(Name of Architect/Contractor - Phone #)
Site plans received
Site plans returned for revision
Site plans approved/returned
Facility plans received
Facility plans approved/returned
Operation plans received
Operation plans approved/returned
CRC Satisfactory Preliminary
Application for license received
Readiness statement received
Licensure study visit
First day of operation approval
File to Regional Director
NAME OF FACILITY: _______________________________________________
STREET ADDRESS: _________________________________________________
CITY/ZIP CODE: ____________________________________________________
AREA CODE/TELEPHONE NUMBER: ____________________________________
This is to certify that I have met all applicable rules as evidenced by the following:
A. Plans have been submitted to and approved by local building and fire safety authorities and Child Care Licensing.
B. I have taken all action as outlined in my approved site plan, facility plan, and operation plan:
2. A copy of the local building authority approval is attached.
3. If there are no building ordinances in effect in your
jurisdiction, submit a copy of a statement from a licensed electrician
and/or a gas representative verifying that the following have been installed
according to manufacturer's recommendations:
b. Cooking equipment
c. Hot water heater
d. Wiring installed according to code
4. If other than approved community system, a copy of approval for a well and/or a septic tank with size and capacity of tank is attached.
5. A copy of Food Service permit and current food service inspection report, if applicable.
6. A copy of Health Department inspection.
7. A statement from the local zoning authority verifying compliance with local ordinances, if applicable.
Director, on ____________ and ________________ person
in charge in director's absence, on
D. Employee criminal records check application(s) submitted for the following:
E. Facility is equipped with furniture as required and ready for use.
F. The outdoor play space is equipped and ready for use.
I am ready for a licensing inspection to be scheduled. I understand that only one (1) visit will be made prior to taking action on my application for a license, and unless all applicable rules have been met the license will be denied. I further understand that Georgia Law prevents me from reapplying for a license for one (1) year after a license application has been denied.
Enclosed is a map with directions to my center. I hereby request an on-site inspection to assess compliance with rules. Please contact me at the following telephone number between the hours of 8:00 a.m. and 4:00 p.m. to inform me of the scheduled licensure date.
Area Code/Telephone Number
Applicant's Signature Date