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Objective: Exploring several health and safety practices in child care centers (CCCs) in Pennsylvania (PA). Design and Methods: A prospective observational study of a convenience sample of CCCs was done. On-site evaluations included direct observation of hand washing behaviors, infant sleep position, playground equipment safety, and an assessment of safety policies. Results: Evaluations were done at 134 sites. The director's median time in her current position was 2.5 years; 32% of the providers worked at the site less than one year. Sixteen (12%) sites had consulted a doctor on health policy development. Of 114 food preparation or consumption observations, 88 (77%) of the adults and 100 (92%) of the children washed their hands; and, of 181 diapering or toileting observations, 78 (83%) of the adults and 103 (95%) of the children washed their hands. Staff placed 67% of infants on their backs for sleep. Safe playground surfacing was observed surrounding 10 (21%) indoor and 52 (57%) outdoor equipment areas. Overall, suburban, non-profit, parent funded centers performed better than urban, for profit, state funded centers—except for sleep positioning when the opposite association was observed. Conclusion: Many CCCs lack adequate health and safety practices especially those sites that were urban, for profit, or were predominately state funded. Improving the training of staff, updating or increasing comprehensive and accurate policies, and obtaining input from skilled health professionals may improve safety in CCCs.