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, the Government Accountability Office (GAO) was asked to follow up on their 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, GAO 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. Among their findings, GAO found that in 2003, 38 states exempted all family child care providers from being regulated, compared with 39 states in 1999. Most states conducted compliance inspections at least once a year, meeting or exceeding the recommended level for all types of providers. Forty-three states reported assigning staff to geographic locations throughout the state. Forty-five states reported using technology to assist them with many aspects of licensing and enforcement functions, such as maintaining statistics on families and providers. Seven appendixes present: (1) study scope and methodology; (2) state caseloads, fiscal years 2003 and 1999; (3) state child care licensing budget and full-time equivalent staffing levels, 1999 and 2003; (4) frequency of licensure and monitoring visits in the states; (5) state survey; (6) comments from the Department of Health and Human Services; and (7) GAO contact and staff acknowledgments. (Contains 20 footnotes, 5 figures, and 3 tables.)