States are responsible for developing licensing criteria and health and safety requirements and conducting enforcement activities to ensure providers comply with them and thereby protect the safety and health of children in child care settings. While the federal government's role is limited in this area, the states must certify that they have safety and health requirements in place and procedures to ensure providers comply with all applicable requirements to receive federal CCDF funds. The Department of Health and Human Services (HHS) oversees CCDF. In fiscal year 2003, the amount of federal funds appropriated for CCDF was $4.8 billion. The CCDF funds are provided to states through a block grant mechanism which allows states to set priorities, establish policies, and spend funds in ways that will help them achieve state child care goals. The Child Care and Development Block Grant statute that underlies the CCDF requires states to designate a lead agency and to establish state plans that commit to establishing and enforcing licensing requirements and health and safety standards for child care providers. The statute leaves it to the states to decide what requirements are to be applicable to specific categories of providers, but for health and safety it sets out three broad parameters that must apply to all providers receiving federal assistance: physical premises safety, staff training, and control of infectious diseases (including childhood immunizations). To qualify for a subsidy provided with funds from the CCDF, a provider must comply with these and any other applicable state requirements. To be eligible for CCDF subsidies, parents must be working, in training, or attending an educational program and have children less than 13 years of age. States can set income eligibility limits at or below 85 percent of the state median income level. States must use a significant portion of their CCDF funds for families receiving Temporary Assistance for Needy Families (TANF) or families who are at risk for becoming dependent upon public assistance. CCDF has five goals: (1) encouraging maximum flexibility in developing state child care programs; (2) promoting parental choice; (3) encouraging states to provide consumer education information to parents; (4) helping states provide child care to parents trying to become independent of public assistance; and (5) helping states implement health, safety, licensing, and registration standards established in state regulations. However, CCDF does not specify how the states should meet these goals and only requires them to be included as elements within the state child care plan. States can also determine which enforcement activities apply to different types of child care. Types of child care eligible to receive funding under TANF and the block grant are described in table 1. States regulate those providers over which they have authority by setting requirements, including those focusing on health and safety, that such child care providers must meet and by enforcing these requirements. State child care licensing offices are responsible for enforcing such health and safety requirements, and engage in different oversight activities for licensed providers and for regulated nonlicensed providers. Licensed providers are generally subject to standard oversight, which generally includes background checks, inspections, technical assistance and training, and the application of sanctions when providers are found to be out of compliance. Regulated nonlicensed providers receive less intense oversight. Such oversight can include self-certification that health and safety standards have been met, background checks, and sanctions. Providers who are legally exempt by state law from oversight are not regulated by state child care licensing offices. For example, in certain states, child care centers run by religious organizations may be exempt. In addition, under federal regulations, the states are not required to apply health and safety requirements to certain providers who only care for a child to whom they are related. Some states may conduct background checks and inspections of their legally exempt providers. States vary as to which types or subtypes of child care providers fall under each level of oversight. When establishing which providers will be required to obtain licenses, and hence be subject to standard oversight, and which will be required to comply with less intense requirements, states consider a number of factors. For example, states consider whether certain providers are subject to other health and safety regulating authorities, such as school- based programs that must conform to all health and safety requirements required for public schools and are overseen by the state education department. States also consider the staffing resources they would need to carry out the necessary licensing and enforcement activities in light of their budget, how to target resources toward the greatest number of children, and the impact that licensing activities could have on child care availability and parental choice. For example, some providers might pass the costs of conforming with licensing requirements on to parents, which could make such care too expensive for some parents. Currently, states are making choices about the extent to which they license certain providers and about which enforcement activities apply to different types of providers. There are no specified federal requirements for licensing and enforcement activities, so many states rely on recommendations made by professional organizations in developing their own standards. Professional organizations recommend standards for several critical licensing and enforcement activities, including background checks, monitoring visits, training for licensing staff, and caseload size. Table 2 outlines recommended practices for critical licensing and enforcement activities. In 2003, the median caseload size for inspectors decreased, but most licensing and enforcement activities for licensed providers remained about the same as those in 1999. Almost a quarter of the states maintained caseloads at recommend levels, and fewer states had caseloads levels over 150. Most states conducted compliance inspections at least once a year, which met or exceeded the recommended level for all types of providers. However, most states do not require the amount of training recommended by national professional organizations. Most states continued monitoring exempt providers by distributing information about health and safety requirements and asking these providers to certify that they complied with state requirements, although some states engaged in more intense monitoring practices for these providers. In 2003, almost a quarter of the states maintained caseloads at or below the recommended level of 75 facilities to one inspector, and the number doing so had increased by 1 since 1999. Specifically, in 1999, 11 states were meeting the recommended caseload levels, and that number increased to 11 states and the District of Columbia by 2003. The median number of facilities per inspector decreased during this time, from 118 facilities per inspector to 110 facilities per inspector, but the number of facilities per inspector was still well above the recommended level of 75 in 2003. In 1999, caseloads ranged from 52 in Missouri to 333 in Colorado, while in 2003, caseloads ranged from 35 per inspector in Hawaii to 600 per inspector in Iowa. Although the range was broader in 2003 than in 1999, more states decreased the size of their caseloads than increased them. Between 1999 and 2003, the caseload in 23 states and the District of Columbia decreased while the caseload in 16 states increased. The number of states with particularly high caseloads, over 150, dropped from 17 to 15, between 1999 and 2003. Among the states whose caseloads decreased were several states with the some of the highest caseloads in 1999. For example, Colorado's caseload went from 333 to 138 as its licensing budget nearly doubled. Figure 1 illustrates the ranges of caseload levels of licensing staff by state in 2003; see appendix II for a comparison of caseload by state in 1999 and 2003 and appendix III for comparisons of licensing budgets and staffing levels by state in 1999 and 2003. While state data showed 12 states maintaining caseloads at recommended levels, states reported that they were visiting facilities as often as recommended, and in 15 states, more often. States may be managing to visit facilities as often as recommended while maintaining caseloads higher than those recommended, in part because the caseload standard itself is not appropriate for some states. Experts note that this standard does not fully account for time-saving technology that might allow some states to operate effectively with larger than recommended caseloads. Further, licensing staff could be making trade-offs not captured in our survey. For example, staff could be maintaining their schedule for monitoring visits at the expense of performing other duties, including processing applications, providing technical assistance, or documenting inspection visits in a timely manner. According to the data reported through state surveys and NCCIC, one less state exempted family child care providers--sole caregivers who care for children in a private residence other than the child's--than were exempted from health and safety requirements in 1999. In 1999, 39 states exempted some family child care providers from regulation, and by 2003, 38 states were exempting some of these types of providers. In addition, fewer states required licensure for some types of centers in 2003 than had in 1999, including religious centers, federal centers, and recreation centers. See table 3. Many states set thresholds at which regulation begins according to the number of children served by different types of providers and exempt from regulation those providers falling below these thresholds. For example, states commonly determine which family child care providers will be regulated based on the number of children in care. Specifically, in a given state, providers caring for 7 or more children in their home might be regulated, while providers caring for 4 children in their home might be exempted from regulation. As figure 2 illustrates, these regulatory thresholds have changed very little since 1999. However, 18 states met or exceeded the recommended practice of regulating providers who cared for 2 or more unrelated children in 2003, whereas 13 were doing so in 1999. Although some changes had occurred since 1999, states continued to conduct compliance inspections in accordance with recommended practices of conducting compliance inspections at least once a year. However, the number of states that visited facilities at least twice a year dropped by about half for all types of settings. According to the data reported to us through our survey, 41 states inspected centers at least annually, and 32 states did so for group homes. Similarly, 28 states conducted inspection visits to family child care homes at least once a year. See figure 3 and appendix IV. The number of states requiring providers to pursue ongoing training increased from 26 in 1999 to 29 in 2003, and as in 1999, the same number of states (4) specifically followed the recommended practice by requiring at least 24 hours of training per year for center directors, and 3 states required this of center teachers. No states required this level of training for family child care providers. The same number of states (32) required licensing staff to have an academic degree in a related field in 1999 and 2003. Similarly, in 1999 and 2003, the same number of states (33) required licensing staff to have work experience in licensing or a related field before being assigned to licensing and enforcement activities. Finally, although very few states had required licensing staff to pass a test in 1999 (7), even fewer required this in 2004 (3). More states informed exempt, subsidized providers about the requirements under the federal grant by sending them a package of information about health and safety requirements in 2003 (32) as reported doing so in 1999 (28). In addition, 17 states reported informing providers by requiring them to attend a short briefing or orientation sessions. Of these, 13 states both sent them a package of information and required attendance at a briefing or orientation. In monitoring providers exempted from regulation who were receiving CCDF funds, states exercised the wide discretion given them by the grant in determining how, or whether, to enforce state and local safety and health requirements for such providers. Some states monitored such providers relatively intensely, while others did not have the authority to do so under state law. For example, some states conducted background checks on exempt providers or inspected such providers. The number of states conducting background checks and inspections for such providers increased since 1999. For 2003, 37 states reported conducting background checks on exempt providers, compared with 20 in 1999. Similarly, for 2003, 12 states reported conducting inspections for such providers compared with 6 in 1999. Finally, for 2003, 9 states reported conducting both background checks and inspections, while 4 states reported doing so in 1999. While 43 states assigned staff to a geographic location, those states using this broad method varied in the specifics of such assignments. Nineteen states also reported assigning staff based on specific job task, such as responding to complaints. Nineteen states reported assigning staff to inspect a particular type of child care facility, such as centers or family homes. Some states used multiple criteria to organize their staff; these states frequently first assigned staff based on geographic location and then relied on secondary criteria, such as type of child care facility. See figure 4. Forty-five states reported using technology to assist them with many aspects of licensing and enforcement activities. States used technology for tracking and monitoring subsidy use, inspecting facilities, making and reconciling payments to providers, linking state and local agencies, maintaining statistics on providers, maintaining statistics on families, and preparing reports to meet federal and state mandates. See figure 5. Technology to complete some of these tasks was available in only a limited number of locations, such as the state licensing office, while for other tasks the technology could be accessed anywhere in the state by authorized users. More states had the ability to maintain statistics on providers and families (24 states) and preparing reports to meet federal and state mandates (20 states) statewide than for any other tasks (tracing and monitoring subsidy use (18 states), making and reconciling payments (17 states), facility inspection checklist (16 states) or linking state and local agencies (12 states)). States we visited have adopted a number of promising practices to assist in their child care licensing and enforcement activities. First, some states used technology in ways that allowed them to streamline their licensing and enforcement processes and to manage parent and provider information particularly effectively. Second, the states we visited had paired frequent inspections with technical assistance to help ensure that child care providers would meet state health and safety regulations. Third, three states we visited had implemented rating systems that differentiate providers by the quality of care they provide. Such systems have helped parents choose child care providers by allowing them to compare the quality of different providers. In addition, these systems have helped states determine what training and technical assistance each provider needs and have offered providers incentives to improve and maintain the quality of their care. Fourth, all the states we visited encouraged partnerships with community organizations to improve the training and education of providers. For example, states partnered with community colleges to connect providers with educational opportunities and with resource and referral agencies to meet the ongoing training needs of providers. States we visited used technology to make licensing and enforcement information more readily available to providers and parents, save time and resources, and track payments and subsidy use. For example, Florida--the state with the most complete, integrated, and up-to-date technology system of the states we visited--used technology to create an online public information system for providers and parents. Providers can use this system to access online information about state policies and regulations, training requirements, how to start a center, and other information. This has helped providers increase professionalism and self- monitoring, according to state officials. Parents can use the system to access the compliance histories of each provider. In addition, some states have used technology to make critical licensing and enforcement activities more efficient. For example, Florida's Internet- based system allows providers to register for training online and access their transcripts and final examination results. Florida officials also told us that posting provider information online reduced the amount of time child care licensing staff had to spend answering questions from providers and consequently allowed them to spend more time on other enforcement activities. Two states we visited--Florida and North Carolina--have used laptops to make the enforcement process more efficient. Specifically, in these states inspectors were able to enter data into their laptops while conducting inspections rather than having to enter this information into the computer after returning to the office. In addition, inspectors in Florida were able to print a copy of the compliance report for providers while on-site to facilitate discussions of areas needing improvement. The laptops also saved inspectors time by allowing them to quickly access provider information, state child care regulations, noncompliance citations, and inspection forms. Officials in both Florida and North Carolina said that using laptop computers had helped inspectors spend less time on administrative duties and allowed them to spend more time providing on- site technical assistance to providers. The project coordinator in Florida said that this system which only covers child care licensing, was more affordable than other states' licensing systems, which are part of their larger statewide child welfare information systems. In another state, technology was used to make it easier for providers and parents to manage subsidy payments and reduced the likelihood of fraud or overpayment. Specifically, Oklahoma reported using an electronic benefits transfer (EBT) system to automatically calculate payment rates and to track subsidy use. Because Oklahoma reimburses providers at over 160 different rates depending upon the characteristics of the family and provider receiving a subsidy, the likelihood of error had been significantly higher before the system was implemented, when licensing staff were responsible for identifying the appropriate rate. According to state officials, this system has saved time processing paperwork. Further, the EBT system has allowed parents receiving a child care subsidy to document the time and attendance for their children using an EBT card issued by the state, and providers are automatically reimbursed at the appropriate rate. This automated system has also has also helped officials identify instances of child care fraud and payment abuse, according to state officials. We found that in the states we visited, only those that had recently invested in computer systems, such as Florida, had been able to take advantage of new technologies at an affordable price. In contrast, other states that had not recently invested in computer systems, such as Delaware, had been unable to adopt such promising practices. Specifically, although Delaware had been on the leading edge of using technology almost a decade ago, it had been unable to maintain this advantage. One state official said that it is costly to implement and maintain the technology necessary to support facilities inspection, particularly when the state's system is relatively old and needs to be updated. For example, Delaware's system was designed in 1995 to help staff investigate child abuse, but was being used in 2003 to track the licensing process. According to state officials, the system was difficult to use for management purposes. To upgrade the system to adopt promising practices such as entering data while conducting on-site inspections, the state would need to develop the system and obtain additional equipment, such as laptop computers. However, officials told us that despite the increases in the state licensing budget since 1999, the state does not have the funding to upgrade the system and purchase additional technological equipment because these funds had been for specific purposes, such as staffing and infant and toddler programs. Florida, North Carolina, and Oklahoma have implemented rating systems to tie the level of reimbursement to a provider's quality. These rating systems helped create a market system by giving parents more information about the quality of child care providers, and offered incentives to providers to obtain higher levels of education and improve quality in their facilities. In implementing rating systems, states set standards for different tiers of quality and assessed providers against these standards. The lowest tier included those providers who only met the state licensing criteria, while the highest tiers in Florida and Oklahoma included those providers who have achieved accreditation by national organizations. States differ in the number of tiers in their systems: North Carolina has five, Oklahoma has four, and Florida has two tiers. Ratings systems have helped parents choose child care providers by allowing them to compare the quality of different providers. While some parents might not have known whether national accreditation would mean higher-quality care, they can easily identify that a provider with five stars was considered to provide better quality than a provider with one star. Rating systems also offered providers incentives to improve and maintain the quality of their facilities by offering higher levels of reimbursement to higher-quality providers. For example, through the star rating systems in North Carolina and Oklahoma, providers with more stars received a higher rate of reimbursement than providers with one star. Similarly, in Florida high-quality providers also receive financial incentives such as a reimbursement rate for subsidized children that is 20 percent higher than the market rate, a tax break for high-quality providers whose clientele does not include subsidized families, and an exemption from sales tax on educational materials. Officials in Oklahoma said that the rating system has provided incentives to all providers to improve the quality of their care, even providers who do not serve subsidized children. Such providers use the star rating as a marketing tool for their facilities, according to state officials. Finally, the rating systems--and the standards and indicators of quality on which they are based--can help states focus their child care quality efforts. For example, North Carolina's five-star rating system forms the core of all its child care quality efforts, according to state officials. The Stars program provided the criteria for identifying areas in which individual centers needed to improve and the steps centers could take to obtain a higher rating, the basis for developing and providing full-day professional development and workshops throughout the year, and links with financial supports to encourage and reward participation in professional development that could lead to higher-quality child care. Training is an integral part of ensuring and upgrading the quality of early childhood education for all the states we visited. We found promising practices in training and information programs for providers and parents. Training and information for providers includes information on starting up a facility and program standards that may be available in information packages or on the Internet; orientation training; technical assistance; staff development courses; conferences, and model observation training sites. Parent information services includes providing information on what to look for when evaluating child care providers, as well as related information on vaccinations, screening and playground safety and where to access parent support services. Delaware, North Carolina, and Oklahoma were cited by experts as having notable training programs. What they have in common is that each training program is part of a total statewide system of interconnected partnerships between state and community agencies to ensure quality early childhood care. In these three states, licensing officials offered prelicensing training so that potential providers could get information on state requirements to avoid being out of compliance. In Delaware, staff from the Family & Workplace Connection, which is the umbrella organization that provides both training and resource and referral (R&R) services and offered a wide range of training opportunities that included some technical assistance, also attended new provider orientations given by the licensing office, to meet these providers and inform them of other services they supply, like the food program, which can furnish free food to providers, or grant opportunities. According to one official, these supports helped providers understand the health and safety requirements, which in turn helped facilitate compliance. In Delaware, inspectors also walked new providers through the health and safety regulations and addressed providers' questions or concerns on their first walk-through of the facility. The bulk of training for providers was provided by training organizations--community colleges, early education training centers, some R&R agencies, and universities--working in partnership with the licensing offices for ongoing staff development. Such training is designed to help providers meet ongoing training requirements and provide them with technical assistance so they can improve the quality of their care by engaging in training programs aligned with state standards and requirements. Oklahoma, North Carolina, and Delaware pursued different strategies to implement this alignment, and Florida demonstrated how a comprehensive Internet information system saves time for providers, training organizations, and state officials. Oklahoma's three-tiered training program comprehensively addresses all training needs from meeting minimal requirements for child care licensing to the most advanced professional development for early care and education workers and center directors. Tier I is short-term, job-related training that can be counted toward ongoing training requirements. Providers can pursue Tier I training by attending workshops or conferences related to their job, watching videos, and self-directed reading, and by participating in in-service training. Tier II is in-depth training that providers engage in by completing courses approved by the state's Center for Early Childhood Professional Development. Tier III training is advanced training, formal education through credit-bearing courses at accredited colleges, universities, and technology centers that transfer for credit to such schools, leading to the highest levels of the quality enhancement star system, the career development ladder, and the Oklahoma director's credential. North Carolina has woven its provider training into its comprehensive Smart Start program, which is a recognized national model of partnerships working together to meet the needs of young children. As part of this program, the education level of staff is one of three areas on which providers are evaluated when their quality rating is determined. Providers who meet higher standards for education and experience receive more stars because, according to state officials, child care teachers with more early childhood education and experience are prepared to provide children with a more enriching child care experience. Providers can improve their star rating by increasing staff education and experience levels and by employing more teachers with early childhood education credentials and experience. Providers can pursue such credentials by completing certificate or higher education programs offered at community colleges and universities. Such training activities are facilitated and coordinated by the North Carolina Institute for Early Childhood Professional Development. Delaware First, the career development program for early childhood professionals that is operated by the Family & Workplace Connection, has developed Core Curricula--Basic, Advanced, and Specialty--that can be used to fulfill training requirements and also to pursue a Child Development Associate degree or college credit. Florida and Delaware provided training information and administrative functions through the Internet. This has saved time for providers, inspectors, and training organizations by allowing providers to register online for courses offered at community colleges or other organizations offering child care training. In addition, providers and inspectors have been able to access providers' transcripts online. State officials say that this program has saved the state time and money, although no studies have been done to quantify these savings. Other state officials have noted that using an Internet system has promoted quality in child care by making the process transparent and easily accessible. In Florida, for example, families seeking quality child care can see the latest the inspection reports on a facility because they are immediately posted on the Internet. According to child care officials and the National Association for the Education of Young Children (NAEYC), training opportunities are maximized and retention rates for child care workers increased when rewards for training and higher quality child care are linked. For example, both North Carolina and Oklahoma offer incentives to providers to encourage them to pursue training. These incentives are offered through a program for college scholarships funded by state, federal, and private dollars (T.E.A.C.H. Early Childhood). Both North Carolina and Oklahoma have also adopted a salary supplement program called WAGE$ to reward increased education attainment. Parent training is provided by R&R organizations in each state, which provide information on the Internet and by telephone, as well as through written brochures, fact sheets, and newsletters. For example, Florida's R&R provides parents a database listing all legally operating child care and early childhood providers, available options for care, indicators of quality to look for when considering a provider, and what to consider when checking on a child's placement, that is, determining how well the placement will meet a child's needs. In Delaware, the R&R offered workshops throughout the year to parents on over 105 topics pertaining to children up to school age. In all four states we visited, the R&R agency provided a system to help parents locate child care--often known as a child care locator--as well as information about how to choose quality care and what training opportunities were available for parents. One expert we interviewed told us that it is important to educate parents because they are the ones who visit the child care facility every day and are most effective in helping to ensure provider compliance with state child care standards. By expanding who is covered by licensing requirements and parental knowledge, states have increased oversight on child care providers since 1999. However, some states have decreased the number of inspections per facility per year. At the same time, states are maintaining their flexibility in administering CCDF and providing parents with choice in the child care options available to them. States use inspections to oversee the child care provided in facilities with the greatest number of children and use less intensive methods like self-certification for other facilities they regulate. Self-certification affords less assurance that providers are meeting safety and health requirements, but in an era when caseload sizes already exceed recommended levels in many states and states find themselves challenged by increasing child care demand, it helps keep low-cost child care available. The use of technology has also increased in the states for state licensing staff, providers, and parents. Not only have the number of states using technology in the areas associated with state activities in new areas, providing information and training resources for parents licensing and enforcement increased, but technology has also expanded into new areas, providing information and training resources for parents, providers, and training organizations on a broad range of topics for a number of different functions. The obvious advantages of an up-to-date, Internet-based, integrated information system have been demonstrated by Florida. However, the size of the investment required for this type of system depends on whether or not the state chooses to create an independent licensing information system, or if the state wants its licensing system to be part of a larger statewide child care information system. Florida found it more affordable to do the former. We provided officials of the Administration for Children and Families (ACF), HHS, an opportunity to comment on a draft of this report. ACF was pleased with the findings and noted that the report will be especially helpful to ACF and the states because it compares state child care health and safety enforcement in 1999 and 2003. ACF's comments are reproduced in appendix VI. ACF also supplied technical comments that were incorporated as appropriate. Unless you publicly announce its contents earlier, we plan no further distribution until 30 days after the date of this letter. At that time we will send copies of this report to the Honorable Wade F. Horn, Assistant Secretary, Administration for Children and Families, HHS; appropriate congressional committees; and other interested parties. In addition, the report will be available at no charge on GAO's Web site at http//:www.gao.gov. If you or your staff have any questions or wish to discuss this material further, please call me on (202) 512-7215. To perform our work, we conducted a mail survey in 2004 of state licensing officials in all 50 states and the District of Columbia about their licensing and enforcement policies and practices in 2003. Specifically, we asked states to report on the frequency of their compliance inspections, background checks, training programs and educational requirements for licensing staff, and caseload sizes. We achieved a response rate of 98 percent, with 49 states and the District of Columbia responding to our survey. Maine did not respond. In our 1999 survey, we achieved a 100 percent response rate. We compared our survey results with a mail survey we conducted in 1999 to identify any changes that had occurred within the past few years. Of the 30 substantive questions on our 2004 survey, 17 were identical to those in the 1999 survey, 1 was a version of another 1999 question, and 12 were new questions. To ensure their reliability, we pretested all new questions with current or former state licensing officials. Rather than using our survey data for the number of states exempting family child care providers' regulation, we used data from the National Child Care Information Center (NCCIC). The responses to question 16 of our survey (on the number of states exempting some family child care homes from state regulation) proved problematic, as it had in the 1999 survey. Callbacks to a sample of respondents whose survey responses differed from data produced by NCCIC showed that respondents misunderstood our question. The NCCIC information was based on published state standards of the regulation threshold point for the number of children served rather than survey data. Therefore we used the NCCIC data in this report to answer this question. Since this was similar to what we had done to compensate for the problems in responses to that question in the 1999 survey, the data for the 2 years are comparable. In addition, we conducted a literature search and interviewed child care licensing experts and state and federal officials to gather information about critical licensing and enforcement activities occurring within the states. The experts we interviewed included university research professors, representatives from public policy organizations, staff from organizations that deal with the policy and practice of providing child care services. With the information we gathered through these expert interviews, we identified and conducted site visits in four states--Delaware, Florida, North Carolina, and Oklahoma--to provide examples of promising practices in licensing and enforcement. We conducted our work between October 2003 and July 2004 in accordance with generally accepted government auditing standards. Data were not available. State that did not respond to this survey. Iowa only provided caseload data for centers. Most state licensing offices reported increases in budgets and the number of full-time equivalent (FTE) staff since1999, although an increase in one did not necessarily reflect an increase in the other. Some states could not provide us with FTE or budget information for particular years. Cannot express as a percentage change because 1999 was zero. Maine did not respond to the survey. Does the state conduct renewal visits? Does the state conduct renewal visits? Does the state conduct renewal visits? Does the state conduct renewal visits? Does the state conduct renewal visits? Does the state conduct renewal visits? Not inspected on a regular basis At least twice a year At least twice a year At least twice a year At least twice a year Less often than once every 2 years At least twice a year At least twice a year At least twice a year At least twice a year Family day care is provided by an individual provider in a private residence other than the child's home. Group homes provide care by two or more providers in a private residence other than the child's home. Centers are nonresidential facilities that provide care for children and include full- and part-time group programs, such as nursery and preschool programs. Maine did not respond to our survey. In addition to the person named above, Margaret Armen, Amy Buck, Patricia Bundy, Kara Kramer, Jerry Sandau, and Jay Smale also made major contributions to this report. Child Care: Recent State Policy Changes Affecting the Availability of Assistance for Low-Income Families. GAO-03-588, May 5, 2003. Child Care: States Exercise Flexibility in Setting Reimbursement Rates and Providing Access for Low-Income Children. GAO-02-894, September 18, 2002. Child Care: States Have Undertaken a Variety of Quality Improvement Initiatives, but More Evaluations of Effectiveness Are Needed. GAO-02-897, September 6, 2002. Child Care: States Increased Spending on Low-Income Families. GAO-01-293, February 2, 2001. Child Care: State Requirements for Background Checks. GAO/HEHS-00-66R, February 28, 2000. Child Care: State Efforts to Enforce Safety and Health Requirements. GAO/HEHS-00-28, January 24, 2000. Child Care: How Do Military and Civilian Center Costs Compare? GAO/HEHS-00-7, October 14, 1999. Welfare Reform: States' Efforts to Expand Child Care Programs. GAO/HEHS-98-27, January 13, 1998.

Summary:
The federal government requires states that receive funds from the Child Care and Development Fund to establish basic health and safety requirements. The federal government also requires states receiving federal funds for child care to have procedures in place to ensure that providers being paid with grant dollars comply with the applicable safety and health requirements. Because of the significant federal role in paying for child care services and congressional concerns about the way in which states ensure the safety and health of children in child care settings, we were asked to follow up on our prior report, Child Care: State Efforts to Enforce Safety and Health Requirements (GAO/HEHS-00-28, Jan. 24, 2000). This report (1) identifies changes in states' licensing and enforcement activities for various types of licensed and nonlicensed providers since 1999, (2) describes the ways child care licensing agencies organize inspection staff and use technology, and (3) provides examples of promising practices in state child care licensing and enforcement activities. To obtain data, we surveyed state licensing officials in 2004 about their 2003 activities, interviewed experts and made site visits to four states--Delaware, Florida, North Carolina and Oklahoma. State efforts in the licensing and oversight of child care facilities are generally about the same as they were in 1999, except that the median caseload of the number of facilities per inspector dropped from 118 to 110 in 2003. We found that in 2003, 38 states exempted all family child care providers from being regulated, compared with 39 states in 1999. Most states conducted compliance inspections at least once a year, meeting or exceeding the recommended level for all types of providers. Many states organized inspection staff by geography and used technology in many parts of the inspection process. Forty-three states reported assigning staff to geographic locations throughout the state. States also assigned staff based on specific job task and type of child care facility the staff would inspect. Many states used multiple criteria to assign staff. Forty-five states reported using technology to assist them with many aspects of licensing and enforcement functions, such as maintaining statistics on families and providers. States have adopted a number of promising practices to assist their child care licensing and enforcement activities. These practices include the use of technology to streamline licensing and enforcement processes and manage parent and provider information, rating systems to aid parents in selecting the appropriate child care for their child and to offer providers incentives to improve and maintain the quality of their care, and working with other organizations to train providers and parents.