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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700237
Report Date: 01/04/2022
Date Signed: 01/06/2022 09:58:18 AM

Document Has Been Signed on 01/06/2022 09:58 AM - 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:
367700237
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cindy RodriguezTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Justin Dorsey conducted an announced visit with Applicant Cindy Rodriguez who guided analyst on a tour of the facility for a pre-licensing Inspection. This is a one story home with 4 bedrooms, 3 bathrooms, kitchen, dining room, family room, front room (converted main care area), laundry room, and attached garage. There is no pool/or body of water on the premises. Family members residing in the home include Family Member #1, Family Member #2 and Family Member #3. Days/hours of operation will be Monday through Sunday from 12:00 AM to 11:30 PM.

Physical Plant: Home is clean and orderly, the home has a fire place which is barricaded by glass, LPA observed age appropriate toys and play equipment, working smoke detector and carbon monoxide detector, 2A10BC Fire Extinguisher serviced 07/2021. Per Applicant no one smokes in the home. The Applicant has a plan and designated area for ill child(ren) as necessary, Per Applicant there are no weapon/firearms in the home, facility sketch complete and current, off limit areas include all of the homes bedrooms, 3 bathrooms, family room, dining room, kitchen, laundry room and garage. There is a working telephone (cell and landline), poisons and cleaning items inaccessible (laundry room & top cabinet in kitchen) to children.

Kitchen/bathroom: The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Sharp items, medications (above the refrigerator counter in a cabinet) and chemicals (laundry room) are inaccessible. Toilets and faucets are clean and operable.

Outdoor: LPA Dorsey observed the homes backyard. The backyard includes a concrete and grass area which children can play. LPA observed the backyard toys and equipment to be in good condition. LPA did not observe any items that could be hazardous to children in care.

Advisory/Other: First Aid kit readily available. CPR/First Aid expire 03/2023. The electrical outlets are covered. LPA Dorsey observed 2 mats for children/infants to nap. Per licensee the children will nap in the main care care area. LPA advised that all infants must have their own crib or play yard. Applicant reminded to supervise children at all times.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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: 367700237
VISIT DATE: 01/04/2022
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Pets: Per Applicant there is one small dog and one cat in the home. LPA did not observe any other pets during the inspection.

LPA Dorsey advised Applicant all adults living/residing in the home are fingerprint cleared and associated.

Documents Provided and or Discussed: The following were discussed regarding Title 22 requirements: Safe Sleep, Documents to be Kept in the Home and Small Family Child Care Home Ratios

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following was discussed with the Applicant:

Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter were reviewed; Applicant reminded that 100% supervision is required at all times to children in care; Applicant made aware that it is her/their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care.

Applicant advised of the requirement to report Unusual Incidents. A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above. The applicant was informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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: 367700237
VISIT DATE: 01/04/2022
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Applicant advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

No corrections needed; LPA Dorsey will submit application to Licensing Program Manager upon returning to the office.



Exit interview conducted and a copy of this report was given to Applicant Cindy Rodriguez.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME:
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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