MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

FAMILY HOME INSPECTION REPORT

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Facility Information

Facility Name
MICKELSON, KRISTINA LYNN

Facility DVN
001838177

Phone
(573) 202-9925

Physical Address
11075 WOODALE DR
ROLLA
MO 65401

Owner
MICKELSON, KRISTINA LYNN

Mailing Address

Provider/Director
MICKELSON, KRISTINA LYNN

E-mail Address
krissmickelson75@gmail.com

Incorporated

Child Care Specialist
LAUREN R RAYWARNKE

Age Range
BIRTH - 13 YEARS

Capacity
10

Facility Type
FAMILY HOME

Limitations
IF ONLY 4 CHILDREN PRESENT, ALL CHILDREN MAY BE UNDER AGE 2 WITH 1 ADULT CAREGIVER; UP TO 10 CHILDREN IN CARE NO MORE THAN 2 CHILDREN UNDER AGE 2 WITH 1 ADULT CAREGIVER; UP TO 10 CHILDREN IN CARE NO MORE THAN 4 CHILDREN UNDER AGE 2 WITH 2 ADULT CAREGIVERS; UP TO 6 CHILDREN IN CARE NO MORE THAN 3 CHILDREN UNDER AGE 2 WITH 1 ADULT CAREGIVER

Inspection Information

Date
10/03/2023

Arrival Time
12:15 PM

Departure Time
1:08 PM

Notice
UNANNOUNCED

Inspection Type
COMPLIANCE MONITORING

Inspection ID
2456017928

Document	Document-Date
OWNER/PROVIDER REFERENCES	02/23/2004
SAMPLE WEEKLY MENU	05/05/2004
SAMPLE FORMS	02/02/2004
DAILY SCHEDULE	02/02/2004
CHILD CARE/DISCIPLINE POLICIES	02/02/2004
POLICIES	02/02/2004
DIAGRAM/OUTDOOR	07/30/2004
DIAGRAM/INDOOR	07/30/2004
ASSISTANT APPROVAL REQUEST	05/25/2010
APPLICATION	08/18/2020
EQUIPMENT LIST	08/05/2023
FIRE/SAFETY INSPECTION	06/01/2023
SANITATION INSPECTION	07/19/2023
ANNUAL DECLARATION	08/05/2023
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS	08/05/2023

Inspection determined facility to be in compliance with licensing rules.

Open Violations: NA

NOTE

The licensee is responsible for compliance with all licensing rules, including but not limited to the rules listed on this compliance report form.

Attendance at Time of Inspection

Total Staff 1

Total Children 6

Staff	Child	Class Age	Note
1	6	MIXED	Kristina Mickelson with 6 children, one child 3 months old, one child 1 year's old, one child age 2 and three children age 3.