Daycare Immunization Requirements in California

1. Why California Is the Strictest State

California's immunization requirements for child care are among the most rigorous in the country. Understanding why helps you explain the rules to parents (and understand why there is no flexibility).

In 2014 and 2015, California experienced significant measles outbreaks, most notably linked to Disneyland in December 2014. The outbreak spread to multiple states and Mexico, and the majority of cases were in unvaccinated or under-vaccinated individuals. Vaccination rates at some schools had dropped below 50%, and personal belief exemptions had been rising steadily for over a decade.

The California Legislature responded with two landmark bills:

• SB 277 (2016) — Eliminated all personal belief exemptions (including religious exemptions) for school and child care entry. Only medical exemptions remained.
• SB 276 / SB 714 (2020) — After reports that some physicians were issuing questionable medical exemptions, the state added oversight. All medical exemptions must now be filed through a state system (CAIR-ME), and CDPH can review and revoke exemptions that don't meet medical standards.

The result: California children in licensed child care must be vaccinated according to the state schedule unless they have a genuine, state-verified medical reason not to be. There is no opt-out for personal, philosophical, or religious reasons. This is a fundamentally different framework than states like Texas (which allows conscience exemptions) or Florida (which allows religious exemptions).

2. Required Vaccines for Child Care Entry

California requires the following vaccines for children enrolling in any licensed child care facility — including child care centers, day nurseries, nursery schools, family child care homes (large), and development centers. These requirements are set by CDPH under California Health and Safety Code Section 120325 and Title 17 of the California Code of Regulations.

3. Vaccine Schedule by Age at Enrollment

The number of doses required for each vaccine depends on the child's age when they first enter child care. California uses age-based checkpoints, and the requirements increase as the child gets older. This table is based on CDPH form IMM-230 (the official California child care immunization schedule).

* Hib note: One dose of Hib must be given on or after the child's 1st birthday, regardless of how many doses were given before. Hib is required only for children younger than 4 years and 6 months at certain age checkpoints (and not required at all for children 5 and older).

MMR and Varicella timing: Both MMR and Varicella require at least one dose given on or after the child's 1st birthday. Doses given before the 1st birthday do not count toward the requirement.

4. The CDPH 286 — California's "Blue Card"

The CDPH 286, officially titled the California School Immunization Record, is the form you will deal with more than any other immunization document. It is commonly called the "blue card" because it is traditionally printed on blue paper.

What It Is

The CDPH 286 is the standardized form that documents a child's immunization status for school and child care entry in California. It records which vaccines the child has received, how many doses, the dates of each dose, and whether the child meets California's immunization requirements, has a medical exemption, or is conditionally admitted.

Who Fills It Out

You do. This is a critical point that many new providers miss. The blue card is completed by child care or school staff — not by the child's doctor. You fill it out using the immunization records provided by the parent or guardian. The parent gives you the child's official immunization record from their pediatrician, and you transfer that information onto the CDPH 286.

You can also retrieve immunization information from CAIR (California Immunization Registry) and from the School and Child Care Roster Lookup tool (SCRL), which can print pre-filled blue cards.

What It Documents

• Child's name, date of birth, and enrollment information
• Each required vaccine and the date(s) each dose was administered
• Whether requirements are met, conditional, or exempt
• Medical exemption status (if applicable)
• Notes on the admitting checkpoints (which age group the child falls into)

Where to Get It

Blue cards are available free of charge from your local county health department. You can also download the form from the CDPH website. The CAIR system and SCRL tool can generate pre-populated blue cards if the child's immunization data is in the registry.

Where It Must Be Kept

The completed CDPH 286, or equivalent immunization documentation, must be kept in the child's file at your facility for as long as the child is enrolled. This is required by LIC 311A (Records to Be Maintained at the Facility) and Title 22 Section 101221. It is one of the items inspectors specifically check during licensing visits.

5. Exemption Policy: Medical Only, Period

This section is the most important in this entire guide for daycare operators new to California. It is where California diverges sharply from almost every other state.

Note: Prior to 2016, California allowed personal belief exemptions (which included religious beliefs). Parents who had filed a personal belief exemption before January 1, 2016 were grandfathered until the child's next immunization checkpoint (typically kindergarten entry). As of 2026, this grandfather period has long since expired. No valid personal belief exemptions remain in the system.

6. SB 277 Explained: No More Personal Belief Exemptions

What SB 277 Changed

Before SB 277, California law allowed parents to opt out of immunization requirements by filing a "personal belief exemption" — a simple signed form stating that immunization was against their beliefs. No doctor's visit was required. The exemption covered both philosophical and religious objections.

SB 277 struck that provision from the law. After January 1, 2016, the only way a child can attend child care or school without the required vaccines is with a medical exemption signed by a licensed physician.

What It Means for Daycare Operators

• You cannot accept any document claiming a personal belief, philosophical, or religious exemption
• If a parent says their child has a "religious exemption," you must explain that California does not offer them
• The only exemption paperwork you can accept is a medical exemption from a licensed MD or DO, filed through the CAIR-ME system
• Home-schooled children and those in independent study are exempt from the law (they are not in a "school" or "child care facility"), but this is not relevant to your daycare operation

7. SB 276 Explained: Medical Exemption Oversight

Why This Law Was Needed

After SB 277 eliminated personal belief exemptions, medical exemption rates increased significantly in some areas. Reports emerged that a small number of physicians were issuing medical exemptions to large numbers of children, sometimes for reasons that did not align with established medical guidelines. SB 276 and its companion bill SB 714 were passed to address this.

What SB 276 / SB 714 Changed

• Electronic filing: All new medical exemptions must be submitted through CAIR-ME, the online Medical Exemption module of the California Immunization Registry. Paper-only medical exemptions are no longer accepted for new requests.
• State review: CDPH can review medical exemptions. If a medical exemption does not meet CDC, ACIP (Advisory Committee on Immunization Practices), or AAP (American Academy of Pediatrics) guidelines, CDPH can revoke it.
• Physician accountability: Physicians who issue 5 or more medical exemptions in a year, or who issue exemptions for schools with immunization rates below 95%, may face additional scrutiny from CDPH.
• Standardized form: The medical exemption is now a standardized digital form, not a free-form doctor's note. This makes it easier for you to verify.

8. How Medical Exemptions Work

If a parent tells you their child has a medical exemption, here is what the process looks like and what you need to verify.

The Step-by-Step Process

1. Parent creates a CAIR-ME account The parent goes to the CAIR-ME website (cair.cdph.ca.gov/exemptions/home) and creates an account. They enter their child's information and the county where the child will attend child care. They select the grade span (childcare/preschool).
2. Parent receives a Medical Exemption Request Number After submitting the request, the system generates a unique request number. The parent gives this number to their child's doctor.
3. Physician issues the exemption in CAIR-ME The child's MD or DO (licensed in California) logs into CAIR-ME, looks up the request number, enters the medical information justifying the exemption, and issues the exemption electronically.
4. Physician provides a printed copy The doctor prints the 2-page standardized medical exemption form from CAIR-ME and gives it to the parent. This is the document the parent gives to you.
5. You file the exemption in the child's record You keep the printed medical exemption form in the child's file alongside the CDPH 286. You note the exemption on the blue card.
6. CDPH may review the exemption CDPH has the authority to review medical exemptions, especially those from physicians who have issued a high number of exemptions or for facilities with low immunization rates. If CDPH revokes an exemption, you will be notified.

What You Need in the File

• The printed 2-page medical exemption form from CAIR-ME (not a free-form doctor's letter)
• The exemption should specify which vaccines are exempted and whether the exemption is permanent or temporary
• The CDPH 286 (blue card) should note the medical exemption status

9. Conditional Admission and Catch-Up Schedules

Not every child will have all required doses at the time of enrollment. California allows conditional admission for children who are in the process of completing their vaccine series. This is not an exemption — it is a temporary status while the child catches up.

When Conditional Admission Applies

A child may be conditionally admitted to child care if:

• The child has received some but not all required doses and is not currently overdue for any doses. For example, a 4-month-old who has received one dose of DTaP (appropriate for their age) but still needs future doses can be admitted conditionally.
• The child is young and will reach new age checkpoints while enrolled. Children younger than 18 months who meet all requirements for their current age will need additional doses as they get older. They are conditionally admitted with the expectation that parents will bring them up to date at each checkpoint.
• The child has a temporary medical exemption. If the physician specifies the exemption is temporary (e.g., due to a short-term medical condition), the child is admitted conditionally until the temporary exemption expires and the vaccine can be given.

Your Obligations for Conditionally Admitted Children

1. Document the conditional status on the CDPH 286 (blue card)
2. Notify the parent in writing of the date by which the child must complete remaining doses
3. Review immunization records at least every 30 days until the child has received all remaining required vaccine doses (per Title 17, Section 6035)
4. Follow up with parents whose children are approaching due dates for additional doses

What Happens If a Child Does Not Complete on Time

If a conditionally admitted child becomes overdue for a vaccine dose and the parent does not provide documentation of the dose or a valid medical exemption, the child must be excluded from care until the dose is received. This is not optional — it is required by California law (Title 17, Section 6035). A child who does not meet the immunization requirements and does not qualify for conditional admission or a medical exemption "shall not be admitted" to child care.

10. CAIR — California Immunization Registry

CAIR (California Immunization Registry) is the statewide electronic system that tracks immunization records for Californians. As a child care provider, CAIR is an important tool for verifying children's vaccine histories and managing medical exemptions.

What CAIR Does

• Stores immunization records: When a child receives a vaccine from any participating provider in California, the record is entered into CAIR. This creates a centralized, statewide record.
• Enables verification: You can look up a child's immunization history in CAIR to verify what the parent has provided or to fill in gaps.
• Manages medical exemptions: The CAIR-ME module is where medical exemptions are filed, stored, and reviewed (as required by SB 276).
• Generates blue cards: The SCRL (School and Child Care Roster Lookup) tool connected to CAIR can print pre-populated CDPH 286 forms.
• Supports annual reporting: All child care facilities must submit immunization status reports by December 5 each year using CAIR Hub.

How to Access CAIR

Child care providers can request access to CAIR through their local immunization coordinator or by contacting the CAIR Help Desk. Access requires completing an enrollment form and agreeing to data use terms. Once enrolled, you can use the system to look up children's records, verify immunization status, and generate reports.

Key links:

• CAIR main site: cairweb.org
• CAIR-ME (medical exemptions): cair.cdph.ca.gov/exemptions/home
• CAIR Hub (annual reporting): Access through CAIR portal

11. Staff Immunization Requirements (SB 792)

California does not only require immunizations for children. Under SB 792 (effective September 1, 2016), all adults who work in or volunteer at licensed child care facilities must also meet specific immunization requirements.

Required Staff Vaccines

Staff Exemptions

SB 792 provides the following exemption options for staff:

• Medical exemption: A written statement from a licensed physician that immunization is not safe for the person due to their physical condition or medical circumstances
• Evidence of immunity: A written statement from a physician showing evidence of current immunity (e.g., blood titer confirming immunity to measles)
• Influenza declination: Unlike the children's exemption policy, staff may decline the influenza vaccine by signing a written declaration. This is the one exception to the "no personal exemption" rule — it applies only to flu vaccines for staff, not to any other vaccine or to children.

TB Clearance — LIC 503

In addition to the three vaccines above, all child care staff must have tuberculosis (TB) clearance. This is documented on the LIC 503 Health Screening Report, which is separate from the SB 792 vaccine requirements but equally important for your staff files.

• A TB risk assessment must be administered
• If risk factors are identified, a TB test (skin test or blood test) and examination must be performed
• The screening must be completed not more than one year prior to employment or within 7 days after starting work
• Results must be documented on the LIC 503 form and kept in the employee's personnel file

Conditional Employment for Staff

If a new employee needs additional time to obtain and provide their immunization records, they may be employed conditionally for a maximum of 30 days, provided they sign a written statement attesting that they have been immunized. Proof of immunization must be provided within those 30 days.

12. What the Inspector Checks

When a Licensing Program Analyst (LPA) from CCLD visits your facility, immunization records are reviewed as part of Inspection Domain 2: Children's Records in the CARE (Compliance, Accountability, and Regulatory Effectiveness) Tool. Here is exactly what they look for.

For Each Enrolled Child

1. CDPH 286 (blue card) present in file: The inspector opens the child's file and looks for the blue card. If it is not there, that is an immediate deficiency.
2. Immunizations match the schedule: The inspector checks the doses documented on the blue card against the California immunization schedule for the child's current age. If the child is 2 years old, the blue card should show 4 doses of DTaP, 3 doses of Polio, 1 dose of Hib (on or after 1st birthday), 3 doses of Hep B, 1 dose of MMR, and 1 dose of Varicella.
3. Conditional admission documented properly: If a child is conditionally admitted, the inspector checks whether the conditional status is noted on the blue card, whether the parent was notified of due dates, and whether 30-day reviews are documented.
4. Medical exemption properly filed: If a child has a medical exemption, the inspector verifies that the exemption is the standardized CAIR-ME form (not a random doctor's letter) and that it specifies which vaccines are exempted.
5. No invalid exemptions accepted: If the inspector finds a personal belief or religious exemption in a child's file, that is a deficiency. The child should not be enrolled without proper immunizations.

For Staff Personnel Files

1. Proof of MMR vaccination or immunity
2. Proof of Tdap vaccination
3. Current flu shot documentation or written declination
4. TB clearance on LIC 503

Common Deficiencies

13. Immunization File Checklist

Use this checklist to verify that every child's file and every staff member's file meets California's immunization documentation requirements. This is what you want to have ready when the inspector arrives.

For Each Child's File

For Each Staff Member's Personnel File

14. How California Compares to Other States

If you operate daycare facilities in multiple states, or if you are helping families who have relocated, this comparison shows how dramatically California differs from other large states.

15. Official Resources and Links

Everything in this guide is based on California law and publicly available regulatory documents. Here are the primary sources, bookmarked for your convenience.

Immunization Requirements

• ShotsForSchool.org The official California resource for immunization requirements — the best starting point for both providers and parents
• CDPH — Shots Required for Child Care/Preschool The California Department of Public Health page with child care-specific immunization requirements
• IMM-230 — Child Care Immunization Schedule The official CDPH chart showing required vaccines and doses by age for child care entry
• IMM-222 — Required for Pre-Kindergarten (Child Care) CDPH summary document of immunization requirements for child care

Forms and Records

• CDPH 286 — California School Immunization Record (Blue Card) Download the blue card form — required in every child's file
• LIC 311A — Records to Be Maintained (Centers) The authoritative checklist of every document required in child care center files
• CDPH — Tools for Child Care and Preschool Staff CDPH resource page with forms, guides, and tools specifically for child care providers

Exemption Laws

• SB 277 — Full Bill Text The law that eliminated personal belief exemptions (2016)
• SB 276 — Full Bill Text The law that added state oversight of medical exemptions (2020)
• SB 792 — Full Bill Text The law requiring staff immunizations at child care facilities (2016)
• CDPH — Laws and Exemptions CDPH overview of immunization laws and current exemption policies

CAIR and Medical Exemptions

• CAIR — California Immunization Registry The statewide immunization registry main page
• CAIR-ME — Medical Exemption Portal Where parents and physicians file medical exemptions electronically
• IMM-1466 — Guide for Parents and Physicians on Medical Exemptions CDPH guide explaining the medical exemption process
• SB 276 / SB 714 Q&A — CA Health and Human Services Official Q&A explaining the medical exemption oversight process

Licensing and Regulations

• CDSS Community Care Licensing Division (CCLD) Main page for California child care licensing
• Title 22, Section 101220.1 — Immunizations The specific Title 22 regulation on immunizations for child care
• Title 17, Section 6035 — Conditional Admission The regulation governing conditional admission for children completing their vaccine series
• Interactive Title 22 Tool — Immunizations Section A searchable, plain-English version of the Title 22 immunization requirements
• CDC Immunization Schedule The federal CDC schedule — useful reference, but California's state requirements take precedence for child care entry

Additional Resources

• Child Care Law Center — Immunization Requirements Guide Plain-English legal guide to immunization requirements from the Child Care Law Center
• California Immunization Coalition Statewide coalition providing immunization resources and education
• California Immunization Handbook (13th Edition) The comprehensive CDPH handbook covering all immunization requirements and procedures