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.