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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700493
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:32:32 PM

Document Has Been Signed on 07/21/2022 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
197700493
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Amy Rodriguez TIME COMPLETED:
01:00 PM
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On 07/21/2022, Licensing Program Analysts (LPAs) Justeene Tamayo and Barbara Beneroso met with Licensee, Amy Rodriguez who guided analyst on a tour of the facility for the One Year Required inspection. This is a two story home with 4 bedrooms, 3 bathrooms, living room, family room, dinning room, kitchen, rear yard, attached garage and laundry room. There is no pool/spa or body of water on the premises. Upon arrival LPAs observed 6 preschool children in care. Family members residing in the home include 2 adults (licensee and licensee's husband) and two children. Facility operation are Monday-Friday 7AM-5:30PM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the downstairs guest bedroom. Children use the bathroom in the hallway next to the main care area. Children have access to the downstairs guest bedroom, bathroom next to the guest bedroom, and the backyard. Off limit areas include: entire upstairs area, 3 bedrooms, 2 bathroom, attached garage that remains locked at all times, laundry room that remains locked at all times, living room, family room, dinning room and kitchen. The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (in laundry room with key lock and under kitchen sink with child safety lock), medicines (in upper kitchen cabinet above the refrigerator ) and hazardous items (sharp knives in kitchen drawer with child safety lock) that can pose a danger to children. LPAs observed the fireplace in the living room properly screened. LPAs observed one safety gate barricading the hallway to make the kitchen and living room inaccessible. LPAs also observed another safety gate barricading the stairs and family room. Safe and age appropriate toys, play equipment and materials.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700493
VISIT DATE: 07/21/2022
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The smoke detector and carbon monoxide detector, Fire Extinguisher (2A10BC) are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in family room. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (cell).

Fire/disaster drills are current. Last fire/disaster drill completed on 07/21/22.

Roster is complete. Per licensee, she enrolled new children at her facility and is in the process of updating a current roster. LPAs reminded licensee her roster must be maintained current at all times

Bathroom: Shower/tub are free of hazards (child care bathroom). LPAs did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. LPAs observed the kitchen to be off limits with a children's safety gate. Cleaning supplies are under the kitchen sink (off limit with children's safety lock). Breakfast, lunch, snacks and dinner are provided. Licensee currently has a food program.

Naps are provided in the main care area. Children use cots for nap time. During file review and interview, it was disclosed that licensee was unaware of documenting infants sleep patterns on a sleep log. LPAs discussed Safe Sleep Regulations and provided licensee a copy of the Safe Sleep Log. Facility has been cited a Type B Citation. Please see LIC 809-D
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700493
VISIT DATE: 07/21/2022
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Outdoor: The backyard is safe for children. The backyard is completely fenced (with block cement). There is no body of water. LPAs observed both sides of home barricaded with a safety gate and side fence with self-latch. LPAs observed two BBQ pits (one with a lock and the other covered). LPAs observed age appropriate toys. Per licensee, there are no pets on the premises

Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 05/21/2023. Mandated Reporter expired on 03/18/2020. Licensee will retake the training and send proof of completion to LPA Beneroso. There are no window cords accessible to children.

Documents Provided and or Discussed: Roster, Safe Sleep PIN 20-24-CCP, Individual Sleeping Plan LIC 9227, and Safe Sleep Log. LPA Tamayo provided a copy of the Safe Sleep PIN 20-24-CCP, Safe Sleep Log, and LIC9227. Licensee stated currently does not have child care insurance.

Licensee Rodriguez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee Rodriguez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2022 02:32 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 07/21/2022 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, record review, the licensee did not comply with the section cited above. Licensee was unaware of documenting infants sleep patterns every 15 minutes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will submit proof of documentation of infants sleep log to LPA Tamayo no later than 08/11/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mariela Ramon
LICENSING EVALUATOR NAME:Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700493
VISIT DATE: 07/21/2022
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A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Amy Rodriguez along with her appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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