Caring for Our Children (CFOC)

Chapter 5: Facilities, Supplies, Equipment, and Environmental Health

5.4 Space and Equipment in Designated Areas

5.4.1 Toilet and Handwashing Areas

5.4.1.1: General Requirements for Toilet and Handwashing Areas


Clean toilet and handwashing facilities should be located in the best place to meet the developmental needs of children.

For infant areas, toilets and handwashing facilities are for adult rather than child use. They should be located within the infant area to reduce staff absence.

For toddler areas, toilet and handwashing facilities should be located in or adjacent to the toddler rooms.

For preschool and school-age children, toilet and handwashing facilities should be located near the entrance to the group room and near the entrance to the playground. If both entrances are close to each other, then only one set of toilet and handwashing facilities is needed.

RATIONALE
Young children have poor bowel and bladder control and cannot wait long when they have to use the toilet (1). Young children must be able to get to toilet facilities quickly. Staff must have easy access to hand washing facilities to wash their hands at the times when it is appropriate and still maintain supervision of the children.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.3 Assisting Children with Hand Hygiene
REFERENCES
  1. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

5.4.1.2: Location of Toilets and Privacy Issues


Toilets should be located in rooms separate from those used for cooking or eating. If toilets are not on the same floor as the child care area and not within sight or hearing of a caregiver/teacher, an adult should accompany children younger than five years of age to and from the toilet area. In centers, males and females who are six years of age and older should have separate and private toilet facilities. Younger children who request privacy and have shown capability to use toilet facilities properly should be given permission to use separate and private toilet facilities.
RATIONALE
It is important to prevent contamination of food and to eliminate unpleasant odors from the food areas.

Supervision and assistance are necessary for young children. Although cultures differ in privacy needs, sex-separated toileting among people who are not relatives is the norm for adults. Children should be allowed the opportunity to practice modesty when independent toileting behavior is well-established in the majority of the group. By six years of age, most children can use the toilet by themselves (1).

COMMENTS
Compliance is monitored by observation.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.4.1.3 Gender and Body Awareness
REFERENCES
  1. Shelov, S. P., R. E. Hannemann, eds. 1998. Caring for your baby and young child: Birth to age 5. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

5.4.1.3: Ability to Open Toilet Room Doors


Children should be able to easily open every toilet room door from the inside, and caregivers/teachers should be able to easily open toilet room doors from the outside if adult assistance is required.
RATIONALE
Doors that can be opened easily will prevent entrapment.
COMMENTS
Inside latches that children can easily manage will allow the child to ensure privacy when using the toilet. The latch or lock available for use, must be of a type that the staff can easily open from the outside in case a child requires adult assistance.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

5.4.1.4: Preventing Entry to Toilet Rooms by Infants and Toddlers


Toilet rooms should have barriers that prevent entry by infants and toddlers who are unattended. Infants and toddlers should be supervised by sight and sound at all times.
RATIONALE
Infants and toddlers can drown in toilet bowls, play in the toilet, have contact with contaminated items or surfaces, or otherwise engage in potentially injurious behavior if they are not supervised in toilet rooms.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

5.4.1.5: Chemical Toilets


Chemical toilets should not be used in child care facilities unless they are provided as a temporary measure in the event that the facility’s normal plumbed toilets are not functioning. Constant supervision should be required for young children using a chemical toilet. In the event that chemical toilets may be required on a temporary basis, the caregiver/teacher should seek approval for use from the regulatory health agency.
RATIONALE
Chemical toilets can pose a safety hazard to young children. Young children climbing on the toilet seat could fall through the opening and into the chemical that is contained in the waste receptacle.
COMMENTS
A chemical toilet is a toilet consisting of a seat or bowl attached to a container holding a chemical solution that changes waste into sludge (1).
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
REFERENCES
  1. Dictionary.com. 2000. Chemical toilets. The American heritage dictionary of the English language. 4th ed. http://dictionary.reference.com/browse/chemical toilets.

5.4.1.6: Ratios of Toilets, Urinals, and Hand Sinks to Children


Toilets and hand sinks should be easily accessible to children and facilitate adult supervision. The number of toilets and hand sinks should be subject to the following minimums:

  1. Toddlers:
    1. If each group size is less than ten children, provide one sink and one toilet per group.
  2. Preschool-age children:
    1. If each group size is less than ten children, provide one sink and one toilet per group;
    2. If each group size is between ten to sixteen children, provide two sinks and two flush toilets for each group.
  3. School-age children:
    1. If each group size is less than ten children, provide one sink and one toilet per group;
    2. If each group size is between ten to twenty children, provide two sinks and two toilets per group. Provide separation of male and female toilets.

For toddlers and preschoolers, the maximum toilet height should be eleven inches, and maximum height for hand sinks should be twenty-two inches. Urinals should not exceed 30% of the total required toilet fixtures and should be used by one child at a time. For school-age children, standard height toilet, urinal, and hand sink fixtures are appropriate.

Non-flushing equipment in toilet learning/training should not be counted as toilets in the toilet:child ratio.

RATIONALE
The environment can become contaminated more easily with multiple simultaneous users of urinals, because at least one of the children must assume an off-center position in relationship to the fixture during voiding.

Young children use the toilet frequently and cannot wait long when they have to use the toilet. The ratio of 1:10 is based on best professional experience of early childhood educators who are facility operators (1). This ratio also limits the group that will be sharing facilities (and infections).

COMMENTS
The ratios of toilets and hand sinks to children provided above takes into consideration the maximum group size specified under Standard 1.1.1.2. Local building codes also dictate toilet and sink requirements based on number of children utilizing them.

State licensing regulations have often applied a ratio of 1:10 for toddlers and preschool children, and 1:15 for school-age children. The ratios used in this standard correspond to the maximum group sizes for each age group specified in Standard 1.1.1.2.

A ratio of one toilet to every ten children may not be sufficient if only one toilet is accessible to each group of ten, so a minimum of two toilets per group is preferable when the group size approaches ten. However, a large toilet room with many toilets used by several groups is less desirable than several small toilet rooms assigned to specific groups, because of the opportunities such a large room offers for transmitting infectious disease agents.

When providing bathroom fixtures for a mixed group of preschool and school-age children, requiring a school-age child to use bathroom fixtures designed for preschoolers may negatively impact the self-esteem of the school-age child.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home
RELATED STANDARDS
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
REFERENCES
  1. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

5.4.1.7: Toilet Learning and Training Equipment

Content in the standard was modified on 12/20/2022.

Children who are learning to use the toilet should have the right training equipment. Programs should use child-sized toilets; or safe step aids that can be cleaned, and modified toilet seats (for adult-sized toilets). Children should use this equipment only with direct supervision. Staff should clean and disinfect soiled toilets immediately and at the end of each day. Non-flushing toilets (i.e., potty chairs) are strongly discouraged.

Children with special health care needs may need other training equipment, accommodations, and learning strategies to be successful during toilet training. Early care and education programs should be sensitive to each child’s special needs (i.e., sensory, regulatory, developmental, physical accommodations, etc.). 

RATIONALE

Child-sized toilets that are flushable, step aids that can be cleaned, and modified toilet seats are easier to use and clean. Flushable toilets are better than any type of equipment that exposes the staff to contact with feces or urine. Many infectious diseases can be prevented with proper hygiene and disinfection.1 Research surveys of surfaces in early care and education settings have shown presence of fecal contamination. Fecal contamination has been used to measure the degree of effectiveness in cleaning and disinfecting procedures. Sanitary touching and cleaning of potty chairs is difficult and therefore not recommended.

When early care and education programs think about children with special health care needs by having the proper support and resources, children can overcome any challenges they might face and be successful in toilet training.2

COMMENTS

ADDITIONAL RESOURCES

American Academy of Pediatrics. Virtual Early Education Center. https://veec.aap.org/index.html

Child Care Resource and Referral Network. Supporting the Development of Toileting Skills in Children with Special Needs. https://childcareanswers.org/resources/toileting-the-exceptional-child/

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
REFERENCES

  1. Minnesota Department of Health. Ways to prevent diarrheal illness from spreading at child care and preschool. https://www.health.state.mn.us/diseases/foodborne/daycarepre.html. Accessed September 19, 2022

  2. Child Care Resource and Referral Network. Toileting supports for children with special needs. https://childcareanswers.org/wp-content/uploads/2021/06/Toileting-Special-Needs-Network.pdf. Accessed September 19, 2022

NOTES

Content in the standard was modified on 12/20/2022.

5.4.1.8: Cleaning and Disinfecting Toileting Equipment


Utility gloves and equipment designated for cleaning and disinfecting toilet learning/training equipment and flush toilets should be used for each cleaning and should not be used for other cleaning purposes. Utility gloves should be washed with soapy water and dried after each use.
RATIONALE
Contamination of hands and equipment in a child care room has played a role in the transmission of disease (1,2).
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
Appendix D: Gloving
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child-care centers. Infect Dis Clin North Am 11:347-65.
  2. Van, R., A. L. Morrow, R. R. Reves, L. K. Pickering. 1991. Environmental contamination in child day-care centers. Am J Epidemiol 133:460-70.

5.4.1.9: Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)


Waste receptacles in the facility should be kept clean, in good repair, and emptied daily. Toilet rooms should have at least one plastic-lined waste receptacle with a foot-pedal operated lid.
RATIONALE
This practice prevents the spread of disease and filth. In toilet rooms, users may need to dispose of waste that is contaminated with body fluids. Sanitary disposal of this material requires a lidded container that does not have to be handled to be opened.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas

5.4.1.10: Handwashing Sinks

Content in the STANDARD was modified on 8/9/2017 and 9/21/2023.

Early care and education programs should have at least one sink that they use for only handwashing. Handwashing sinks should:

  • Be easily accessible to staff and children and free of barriers (e.g., doors)
  • Be placed at child height or have a stable, slip proof step or platform so children can reach the sink
  • Be in a place where staff can watch children wash their hands
  • Be cleaned and disinfected regularly
  • Have water temperature set at no more than 120°F1

Handwashing sinks should be equipped with:

  • Clean, running water
  • A foot-pedal operated, electric-eye operated, open, self-closing, slow-closing, or metering faucet that runs water for at least 30 seconds without needing to reactivate the faucet
  • Non-antibacterial, unscented liquid soap
  • Single-use cloths, paper towels, or an air hand dryer with heat guards to prevent contact with hot surfaces

A faucet that runs water colder than 85°F may not be used as a handwashing sink.2 If continuous warm water pressure (above 85°F) is not available, handwashing sinks should run at least 30 seconds of continuous warm water to start and complete handwashing.2 Handwashing sinks should be maintained so they offer proper water temperature and pressure. It is important to follow your state, local, tribal, or territorial regulations to be sure the proper sinks and number of sinks are suitable.

For information on cleaning, disinfecting, and sanitizing see CFOC Appendix K.

For information on choosing a safer cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J.

RATIONALE

Proper handwashing helps prevent the spread of infectious diseases. Proper supplies, location of handwashing sinks, and staff supervision are important for good handwashing routines.2 Foot-pedal operated sinks or automatic handwashing sinks and liquid soap dispensers are preferable because they decrease hand contamination during and after handwashing. The flow of water must continue long enough for the user to wet the skin, get soap, lather for at least 20 seconds, and rinse completely.

Warm water at the proper temperature helps to release soil from hands and encourages proper handwashing techniques. Sinks with added water heater or steam features are not safe for handwashing and could cause burns if water temperature is over 120°F.1

Fragrance-free liquid soap and disposable towels or single-use cloth towels can be used across more than one sink if accessible during handwashing. There is no evidence that antibacterial soap reduces the incidence of illness among children in child care.3 Bar soaps can spread germs among children and staff. Using fragrance-free cleaning products, including soap, reduces exposure to harmful chemicals like phthalates, found in fragrances.3.4

COMMENTS

Posters over the sink are helpful reminders for teaching how to wash hands. Many state and local health departments have created free posters. The CDC has printable handwashing posters: https://www.cdc.gov/handwashing/posters.html

For more information on handwashing sink regulations in your state, visit National Database of Child Care Licensing Regulations.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.2 Handwashing Procedure
3.6.2.2 Space Requirements for Care of Children Who Are Ill
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sinks in Food Preparation Areas
5.2.1.14 Water Heating Devices and Temperatures Allowed
5.2.6.9 Handwashing Sink Using Portable Water Supply
5.4.1.11 Handwashing Sinks Prohibited Uses
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES

  1. American Academy Pediatrics (AAP). 2017. Healthy children. 5 bathroom safety tips for infants & young children. AAP.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Bathroom-Safety.aspx

  2. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2022 Food Code. College Park, MD: FDA; 2023. https://www.fda.gov/media/164194/download

  3. Centers for Disease Control and Prevention (CDC). 2022. Hand hygiene in school and early care and education. CDC.gov Web site. https://www.cdc.gov/handwashing/handwashing-school.html

  4. Clark J, Henk JK, Crandall PG, Crandall MA, O’Bryan CA. An observational study of handwashing compliance in a child care facility. Am. J. Infect. Control. 2016;44(12): 1469–1474. https://doi.org/10.1016/j.ajic.2016.08.006

NOTES

Content in the STANDARD was modified on 8/9/2017 and 9/21/2023.


5.4.1.11: Handwashing Sinks Prohibited Uses

Content in the STANDARD was modified on 9/21/2023.

Sinks in early care and education settings that are designated for handwashing should only be used for handwashing.

Handwashing sinks should not be used for other activities, such as food preparation, rinsing clothes soiled with body fluids, cleaning equipment that is used for toileting, or getting rid of dirty water from cleaning the facility, such as mop water. Handwashing sinks should be cleaned, sanitized, and disinfected regularly, or when obviously dirty, and at the end of the day.

For information on cleaning, sanitizing, and disinfecting, see CFOC Appendix K.

For information on selecting a safer cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J.

RATIONALE

Activities such has diaper changing and food preparation may contaminate sinks with infectious diseases and expose staff and children to germs. Using handwashing sinks to wash or rinse clothes soiled with body fluids or toileting equipment increases the risk of spreading germs in programs. Pouring dirty water into handwashing sinks can contaminate the sink and spread germs to people who are washing their hands in the same sink. Separating handwashing sinks from other sinks and activities in programs helps reduce the risk of cross contamination.1,2

COMMENTS

To prevent the spread of illness, early care and education programs should have more than one sink to separate food preparation, handwashing, and diaper changing. In programs where only one sink is available temporarily, staff should properly clean, sanitize, and/or disinfect the sink between uses. For example, when a handwashing sink is needed for food preparation, programs should properly clean, sanitize and disinfect the sink before preparing any food. Follow all the steps in CFOC Appendix Kand related standards below to clean, sanitize, and disinfect.

For more information and help about safe sink use, talk to a child care health consultant or your state, local, tribal, or territorial public health department.

For more resources on sink regulations in your state, visit National Database of Child Care Licensing Regulations.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.2 Handwashing Procedure
3.6.2.2 Space Requirements for Care of Children Who Are Ill
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sinks in Food Preparation Areas
5.2.6.9 Handwashing Sink Using Portable Water Supply
5.4.1.10 Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES

  1. Kotch IP, Weber DJ, Nguyen V, et al. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics. 2007;120(1):e29–e36. https://doi.org/10.1542/peds.2005-0760

  2. Gyi AA. Handwashing promotion for preventing diarrhea. Gastroenterol. Nurs. March/April 2019;42(2):181-183. DOI: 10.1097/SGA.0000000000000432

NOTES

Content in the STANDARD was modified on 9/21/2023.

5.4.1.12: Mop Sinks


Centers with more than thirty children should have a mop sink. Large and small family child care homes should have a means of obtaining clean water for mopping and disposing of it in a toilet or in a sink used only for such purposes.
RATIONALE
Handwashing and food preparation sinks must not be contaminated by wastewater. Contamination of hands, toys, and equipment in the room plays a role in the transmission of diseases in child care settings (1,2).
COMMENTS
Mop sinks are installed on the floor, similar to a shower pan, and are usually located in janitor’s closets or laundry facilities.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sinks in Food Preparation Areas
5.2.6.9 Handwashing Sink Using Portable Water Supply
REFERENCES
  1. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child-care centers. Infect Dis Clin North Am 11:347-65.
  2. Van, R., A. L. Morrow, R. R. Reves, L. K. Pickering. 1991. Environmental contamination in child day-care centers. Am J Epidemiol 133:460-70.