MEDICATION AND IMMUNIZATIONS

“Immunization” is the process where a person becomes resistant to an infection or disease. Someone can become immunized by getting a shot called a “vaccine.” Vaccine shots protect a person’s immune system from an infection or disease. These shots prevent 2 to 3 million deaths each year.[1]

[1] World Health Organization, “Immunization,” available at http://www.who.int/topics/immunization/en/ (last visited November 16, 2021).

Yes. The state agency that regulates child care, the Community Care Licensing Division, requires shots. A child can be “exempt” or excused from shots only if she or he has a valid medical exemption.[1] Otherwise, a child care provider cannot allow a child without shots into her or his child care.[2]

[1] Cal. Health & Safety Code § 120370 (a)(3); See Cal. Health & Safety Code § 120325 (Legislative intent to exempt children with medical exemptions). See also Cal. Code Regs., tit. 17 § 6000 (defining “pupil” as “means a person admitted to or seeking admission to any school or pre-kindergarten facility” which includes “private or public child care center, day nursery, nursery school, family day care home, pre-school, or development center for young children”); Cal. Code Regs., tit. 17 § 6025 (schedule of required immunizations); Cal. Health & Safety Code §, 120372 (For an immunization exemption to be valid, a parent must submit a request for a medical exemption through the Department of Public Health); Cal Health & Safety Code § 120335(a) (“Governing authority” in child care is the family child care provider or the administrator of a child care center. “Governing authority” in schools is “the governing board of each school district or the authority of each other private or public institution responsible for the operation and control of the institution or the principal or administrator of each school or institution.”). “Parent” in this publication includes legal guardian.

[2] Cal. Health & Safety Code § 120335 (b) (child care providers may not “unconditionally admit any person as a pupil of any … child care center, day nursery, nursery school, family day care home, or development center, unless, prior to his or her first admission to that institution, he or she has been fully immunized.”); Cal. Code Regs., tit. 22 §§ 102418, 101220.1 (children in family child care homes and centers must be immunized against specified diseases before admittance into child care; child care providers may admit children with immunization exemptions (personal beliefs exemption no longer valid), and child care providers must maintain immunization and immunization exemption records).

• Haemophilus influenza type b (Hib meningitis)
• DTaP (diphtheria, tetanus, pertussis/whooping cough)
• MMR (measles, mumps, rubella)
• Polio
• Hepatitis B
• Varicella (chickenpox)

For a list of shots required by age, see http://www.shotsforschool.org/child–care/.

Yes. A child can be exempt from the required shots only because of her or his physical condition or medical circumstances. California no longer allows exemptions based on religious or personal beliefs.[1] But, if more shots become required by the California Department of Public Health, Personal Beliefs Exemptions will be allowed.[2]

Note: The law is unsettled about whether a child who has an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP), and does not have the necessary vaccinations or a valid medical exemption can be prevented from attending child care or school.

[1] The passage of Senate Bill 277, effective January 1, 2016, eliminated the personal beliefs exemption.

[2] Cal. Health & Safety Code § 120338.

A valid medical exemption is a letter from a licensed doctor.[1] To get a valid medical exemption, a child’s parent or guardian must submit this exemption to the child’s family child care home or child care center.[2]

Starting January 1, 2021, the Department of Public Health is required to create a website for parents to request medical exemptions from vaccinations for their children and for physicians to issue and manage medical exemptions for children in child care.[3]

More information about the request or accessing a request for medical exemption can be found at the following website: https://cair.cdph.ca.gov/exemptions/home 

A “temporary medical exemption” is a type of medical exemption that excuses a child from getting shots for a limited period of time, because of a medical condition.[4] A temporary exemption cannot exceed more than one year.[5] A “permanent medical exemption” is for a medical condition that permanently exempts a child from vaccination.[6] However all medical exemptions cannot extend beyond the grade span discussed in Question 7 below.[7]

[1] Cal. Health & Safety Code § 120370.

[2] See Cal. Code Regs., tit. 17 § 6051.

[3] Cal. Health & Safety Code § 120382 (a).

[4] See Cal. Code Regs., tit. 17 § 6050.

[5] Cal. Health & Safety Code § 120372(a)(2)(G).

[6] See Cal. Code Regs., tit. 17 § 6051 (portion about the “personal beliefs exemption” is no longer valid).

[7] Cal. Health & Safety Code § 120372(a)(2)(G).

Federal and state civil rights laws may protect children who get an exemption because of a medical condition.[1] Parents may sue a child care provider and/or file a discrimination complaint against a child care provider who will not admit a child with a valid medical exemption. If a parent of an excluded child does this, it could be very expensive for a child care provider.

If a child with a valid medical exemption has been denied from a child care facility, parents may also file a complaint with the California Department of Social Services, Child Care Licensing Division.

Note: If a child has not received all of her or his shots for a particular disease, she or he may be excluded if there is good cause to believe that child was exposed to the disease during an outbreak.[2]

[1] The Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101, et seq., the California Unruh Civil Rights Act, Cal. Civ. Code § 51, et seq., and California Disabled Persons Act, § 54, et seq. prevent child care centers and family child care homes from discriminating against a child based on his or her disability. 

[2] Cal. Health & Safety Code § 120370(b). 

It depends. Personal Beliefs Exemptions meet the shot requirements until a child’s next “grade span.” Each grade span is below: 

1. Birth – Preschool
2. Transitional Kindergarten (TK) – 6th grade 
3. 7th – 12th grades

Personal Beliefs Exemptions are no longer valid when a child reaches the end of her or his grade span. The exemption can be transferred between schools within the same grade span.[1]

EXAMPLE: Billy just graduated from preschool and will now attend TK. Billy’s mom filed a Personal Beliefs Exemption at Billy’s preschool when he started in December 2015. Is this Personal Beliefs Exemption still valid when Billy starts TK?  No, Billy’s Personal Beliefs Exemption is no longer valid in Billy’s new grade span. He must now receive the required shots to be enrolled in TK.

[1] See Cal. Health & Safety Code § 120335(g)(1).

Even if a child has not yet received certain required shots, she or he may be admitted “conditionally” to child care for one or more of the following reasons:  

• The child is less than 18 months old, has received all required shots for her or his age, and is waiting for additional shot dose(s) or booster(s). When more doses of a shot are due, this child must get them. The child’s parent or guardian must be informed of the date(s) when new doses are due.  
• The child has not yet received all required shots for her or his age group, but has started receiving doses. When admitted, this child must not be due for any additional doses, and will receive the additional doses when due. The parent or guardian must be informed of the date(s) when new doses are due. 
• The child has a valid medical exemption. Children with a “temporary medical exemption” must receive the required shots after the exemption ends.[1] A temporary medical exemption cannot last longer than one year.[2]

[1] Cal. Code of Regs., tit. 17, §§ 6035 & 6050. See Cal. Health & Safety Code § 120335 (g)(3) (students cannot be admitted or advance to the 7th grade in a public or private school if the student has not been immunized for her or his age group).

[2] Cal. Health & Safety Code § 120372(a)(2)(G).

Yes. Child care providers must admit a foster child or homeless child with unavailable or missing shot records. The child care and/or school must still get the shot records of the child to make sure the child has received all necessary shots.[1]

EXAMPLE: Jesse is in foster care and does not have a record of his shot history. Is Ms. Fox allowed to admit him to her child care?  Yes, Ms. Fox may still admit Jesse without records of his shots. However, Jesse still must meet his shot requirements. So, if Ms. Fox admits Jesse, she should use her available resources to make sure Jesse receives his shot requirements as soon as possible. The same process applies for homeless children.

[1] Cal. Health & Safety Code § 120341; McKinney-Vento Homeless Assistance Act Education for Homeless Children and Youth, 42 U.S.C. § 11432 (g)(3)(C)-(D).

If a child care provider has good reason to believe that a child who doesn’t have proof of immunization has been exposed to one of the listed contagious diseases, they may temporarily exclude that child from care until a local health officer says the child is no longer at risk of catching or transmitting the disease.[1]

[1] Cal. Health & Safety Code §§ 120370(b)

Inform parents about shots. 

1. Tell parents how you feel about shots and your legal responsibilities, both when you speak with them and in your written contract.
2. Explain the medical shots exemptions and the requirements.
3. Explain that when there is “good cause to believe” that a child without her or his shots has been exposed to a disease listed here, the child may not be allowed to attend your child care until the local public health department decides that the child is no longer at risk of getting the disease.[1]

Sample Contract Language  

“Happy Babies Child Care” believes that shots are important to protect your child’s health and the health of other children in our care. Under California law, I cannot enroll any child without shots, unless they have a valid medical exemption.”

Good Practices

If you enroll a child without her or his shots, make sure the exemption paperwork is complete, signed, and dated within six months of the child entering your care.

As legally required, keep copies of all shots paperwork in the child’s file. This includes exemption paperwork.[2]

Inform all parents that children without shots may be in your care. You may not tell parents whether you currently care for children without shots; you can reveal only that children without shots may be in your care. This rule applies even if you do not offer the names of children without shots.[3] However, if a parent of a child without shots gives you written permission, you can reveal the child’s name to other parents. 

[1] Cal. Health & Safety Code §§ 120370(b), 120335(b) (list of diseases).

[2] Cal. Health & Safety Code §§ 1597.05(b)(2) & 1597.541(b) (child care providers must confirm and maintain evidence of children’s immunization records); Cal. Code Regs., tit. 22 §§ 102418(e)-(g), 101220.1(e)-(g).

[3] See Cal. Code Regs. tit. 22 §§ 102423 (family child care) & 101223 (child care center).

Child care employees and volunteers who provide care and supervision to children at the facility, in a child care must get shots for:

Yes. In California, non-medical staff in both child care centers and family child care homes can administer medication.

State-licensed child care providers may worry about whether their license allows them to administer medications to children in their care. California regulations allow non-medical staff to administer medication if they follow certain safe handling and other requirements.[1]  The requirements include that the staff have written authorization and instructions from the child’s representative, and that the instructions are consistent with the label directions as prescribed by the child’s physician, for a prescription medication, and with the product label directions on the container, for a nonprescription medication.

California law and Licensing guidance also authorize non-medical staff to administer blood glucose monitoring and inhaled medication; any other medication necessary to carry out a physician’s medical orders; and any medication needed in case of emergency.The law and guidance include requirements and best practices for doing so.

The California Health and Safety Code authorizes and outlines requirements for child care staff to administer blood glucose testing and inhaled medications.[2]  A staff person who administers blood glucose testing must register with the State Department of Health Services no later than 30 days after beginning to do so.[3]  Form LIC 9222 provides guidance on how to register. A Form LIC  9166 must be completed for each staff member who administers inhaled medication.

California law allows non-medical staff to carry out a physician’s medical orders for a patient.[4] Licensing’s PIN 2022-02-CCP confirms that this rule authorizes services including but not limited to gastronomy tube feeding and care and insulin administration.

California law also permits IMS in the case of emergency.[5] Licensing PIN 2022-02-CCP confirms that this includes but is not limited to emergency administration of glucagon, epinephrine (e.g. Epi-Pen®), and anti-seizure medication (e.g. Diastat®).

[1] See Cal. Code Regs., Tit. 22 §101226(e) (outlining the safe handling and other requirements for child care centers when administering medication).

[2] Cal. Health & Safety Code §§1596.797 (blood glucose testing) and 1596.798 (inhaled medications).

[3] Cal. Business and Prof. Code § 1241(c).

[4] Cal. Business and Prof. Code section 2727(e). See also, American Nurses Association v. Torlakson, 57 Cal. 4th. 570 (2013)(holding that Business and Professions Code section 2727(e) exempts non-medical school staff carrying out physicians’ medical orders to provide diabetes care from laws prohibiting the unauthorized practice of nursing). 

[5] Cal. Business and Prof. Code §2058(a).

California Code of Regulations, title 22, section 101226(e) outlines Licensing requirements for handling medication.

Licensing PIN-2022-02 recommends that child care providers find additional resources through the National Resource Center for Health and Safety in Child Care and Early Education’s National Health and Safety Performance Standards (“Caring for Our Children”); the University of California, San Francisco’s California Child Care Health Program; and, the U.S. Food and Drug Administration.

Caring for Our Children includes performance standards for Medication Administration.

The California Child Care Health Program offers practical information and advice about Medication Administration.

A child care program can have a general policy that medication should be given at home, whenever possible. However, it cannot apply that general policy in a way that excludes a child because of the child’s disabilities.
Licensing regulations about medication safe handling confusingly say that they apply “where the licensee chooses to handle medications.” However, child care programs cannot choose not to handle medication in situations where separate rules require the child care program to handle medication.
Separate, federal and state disability rights laws require child care programs to handle medication to prevent discrimination against children with disabilities. These laws define discrimination to include refusing to make reasonable changes to policies and practices that would otherwise prevent a child with disabilities from participating on an equal basis. These include medication policies and practices. A child care program cannot rely on a general policy of not providing certain medications, to refuse IMS to a child who needs it because of a disability. For such a child, the program must modify policies and practices to meet the child’s IMS needs so that the child may fully participate, unless doing so would be an “undue burden,” fundamentally alter the nature of the program, or result in a direct threat to the health and safety of others in the program.
The law defines disability as a physical or mental impairment that substantially limits one or more major life activity, or having a history of or being regarded as having such an impairment. Diabetes, seizure disorders, and life-threatening allergies are examples of relatively common childhood disabilities that may require a child care provider to give a child IMS. They are not exclusive examples.
For more information about including children with disabilities in child care programs, see Child Care Law Center’s Know the Law about the Americans with Disabilities Act (“ADA”) and Child Care in California.
The U.S. Department of Justice’s Civil Rights Division, Disability Rights Section (“DOJ”) is the federal agency responsible for enforcing the ADA. It publishes a resource called, Commonly Asked Questions About Child Care Centers and the Americans with Disabilities Act.

On February 4, 2022, Licensing issued Provider Information Notice (“PIN”) PIN 22-02-CCP, which provides information and best practices for administering IMS in licensed Family Child Care Homes (FCCHs) and Child Care Centers (CCCs).

Licensed child care programs serving children who need IMS should review PIN 22-02-CCP. What follows is a shorter version of information extracted from the PIN.

If the IMS is blood glucose testing or inhaled medication, the licensed child care program must follow the requirements specified in the Health and Safety Code and Business and Professions Code. (See Q. 1, above.)

For other IMS, PIN 22-02-CCP recommends and elaborates on the following as best practices.

FOR FCCHs:

• Obtain authorization, medical orders, and IMS supplies from the child’s authorized representative:
  • Written authorization for each staff who will administer the IMS
  • Medical orders from the child’s physician describing the medical need, the IMS, that it can be safely provided by a layperson, a description of the training needed and who can provide the training, and any symptoms to watch for
  • Medication, equipment and supplies necessary to administer the IMS
• Ensure the presence of trained staff:
  • Obtain the specified training for any staff who will administer the IMS
  • Keep verification of the training in staff personnel records.
  • Plan for the presence of at least one trained staff member when the child is in care, onsite and during offsite activities.
  • Communicate with substitute/new staff about the IMS needs.

• Follow safe storage and other precautions
  • Storage of IMS and related supplies in a safe place inaccessible to children
  • Follow standard precautions such as wearing gloves, washing hands, using safe disposal practices for sharps, and cleaning and disinfecting surfaces that may have been contaminated with body fluids.
  • Record and provide daily information to the child’s representative about when IMS has been administered.
  • Establish Procedures for accepting, maintaining current supplies of, and returning unused IMS

• Meet additional requirements for Emergency IMS
  • Call 911
  • Notify the child’s authorized representative as soon as possible
  • Submit an unusual incident report (LIC 624) to Licensing

• Write an “IMS Plan”
  • An IMS Plan is a document notifying Licensing that the facility is providing IMS
  • The IMS Plan should explain the:
    • Types of IMS the facility is providing
    • Plan for ensuring an adequate number of designated, trained staff
  • Submit a copy to Licensing, and keep a copy at the facility and have all staff know where it is.
  • The facility should report any changes to the IMS Plan to their Licensing Program Analyst or Regional Office

FOR CCCs:

 PIN 22-02-CCP identifies best practices in terms similar to those it applies to FCCHs:

• Obtain authorization, medical orders, and IMS supplies from the child’s authorized representative
• Ensure the presence of trained staff
• Follow safe storage and other precautions
• Meet additional requirements for Emergency IMS
• Write an “IMS Plan”

In applying these best practices, CCCs that provide IMS must follow the Health-Related Services requirements in Title 22, section 101216; Reporting requirements in section 101212; and Disaster and Mass Casualty Plan requirements in section 101174.  PIN 22-02-CCP cross-references Licensing’s recommended best practices to these requirements.

In addition, Licensing expects CCCs to include IMS Plan information in their Plan of Operation required by Title 22, section 101173, and to act accordingly in reporting changes to the IMS Plan.[1]

[1] Cal. Code Regs. Tit. 22, §101212(e)(4)(including reporting changes to Plan of Operation among a center’s Reporting Requirements).

If you are a licensed child care provider and Community Care Licensing is preventing you from administering medications to a child in your care who needs them because of a disability, please contact your local Licensing Regional Office. 

If you are a parent of a child with disabilities and your child care program refuses to administer IMS, you may file a complaint for discrimination with the Department of Justice.

For more information, please contact the Child Care Law Center by phone at, (415) 558-8005 ext. 101 or through our website, here.