The study objectives are to describe child care type and quality experienced by developmentally at-risk children, examine quality differences between Head Start and non-Head Start settings, and identify factors associated with receiving higher-quality child care. Data are analyzed from the Early Childhood Longitudinal Survey, Birth Cohort, a prospective study of a nationally representative sample of US children born in 2001. The sample consisted of 7,500 children who were assessed at 48 months of age. The outcome of interest is child care quality, measured by the Early Childhood Environmental Rating Scale (center care) and the Family Day Care Rating Scale (family day care). Results of descriptive and multivariate regression analyses are presented. Less than one-third of poor children were in Head Start. Child care quality was higher in Head Start centers than other centers, particularly among poor children (4.75 vs. 4.28, p < 0.001), Hispanics (4.90 vs. 4.45, p < 0.001), and whites (4.89 vs. 4.51, p < 0.001). African Americans experienced the lowest quality care in both Head Start and non-Head Start centers. Quality disadvantage was associated with Head Start family care settings, especially for low birthweight children (2.04 in Head Start vs. 3.58 in non-Head Start, p < 0.001). Lower family day care quality was associated with less maternal education and African American and Hispanic ethnicity. Center-based Head Start provides higher quality child care for at-risk children, and expansion of these services will likely facilitate school readiness in these populations. Quality disadvantages in Head Start family day care settings are worrisome and warrant investigation.