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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274450010
Report Date: 07/28/2021
Date Signed: 08/20/2021 01:36:56 PM

Document Has Been Signed on 08/20/2021 01:36 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RODRIGUEZ, IRMAFACILITY NUMBER:
274450010
ADMINISTRATOR:IRMA RODRIGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 757-4583
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
07/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Irma RodriguezTIME COMPLETED:
04:05 PM
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*******THIS IS AN AMENDED REPORT THAT SUPERSEDES REPORT DATED 7/28/2021*********

Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced case management inspection to the home today. LPA met with Irma Rodriguez, Licensee, and explained to her the purpose of the inspection is to deliver an "Order to Individual of Immediate Exclusion for her son Andrew Rodriguez. Licensee stated that her son Andrew does not reside in the licensee's address and provided LPA with Andrew's address for the Licensing Department to send notifications. LPA observed 7 children were in care. LPA handed a copy of the Order to Individual of Immediate Exclusion to the licensee and also provided her with forms LIC 995B "Family Child Care Home Addendum to Notification of Parents' Rights (regarding Removal/Exclusion) both in Spanish and English. LPA instructed the licensee to inform parents of the exclusion of Andrew and obtain signatures from parents and or representatives on the form LIC 995B LPA instructed licensee the requirement to notify the parents/representatives of the current children in care and to the parents of children that she enrolls in the future for as long as she holds a Family Child Care Home license.

No deficiencies were cited today.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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