394500091-9-21-2021-53-CC-ASRN-C742VC-20210921174344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500091
Report Date: 09/21/2021
Date Signed: 09/21/2021 05:43:57 PM

Document Has Been Signed on 09/21/2021 05:43 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	RODRIGUEZ, TERE		FACILITY NUMBER:	394500091
ADMINISTRATOR:	RODRIGUEZ, TERE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 712-3929
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	09/21/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Tere Rodriguez		TIME COMPLETED:	05:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/21/21 Licensing Program Analysts (LPA) Aruna Sridharan met with licensee Tere Rodriguez for unannounced annual inspection. LPA followed infection control protocols. The hours of operation are 7:00am to 6:30pm Monday through Friday. The family child care home facility is single story family home with three bedrooms with two bathrooms, living room, kitchen and garage. Today's census was three infants and four preschoolers and 1 school age child. Off limit areas: Two bedrooms, garage and backyard#2 and #3. Licensee acknowledges that children may never enter these off-limit areas. The backyard is fenced. Licensee was notified that prior to use of any off limits area, the department must be notified and have the approval. A tour of the home, inside and outside, as shown on the facility sketch was conducted. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. The first aid kit is hung on the wall in the dinning area . As per the licensee, there are no firearms or weapons in the home. LPA observed cleaning compound's under the bathroom and kitchen sink with child safety latch. Licensee informed that she does not provide overnight care. Safe toys and play equipment are observed. LPA observed all the required postings, reviewed all staff and childrens records. The children records were incomplete as some documents were missing parent's signatures, two children were missing PM286 and all infants were missing LIC 9227. This is a potential risk and a Type B deficiency was cited. LPA observed the record of licensee’s immunization on file. LPA reviewed children's roster and fire drill log last conducted on 08/01/21. LPA requested a copy of children's roster from the licensee. Licensee had CPR/First aid card that expires on 02/23 and Mandated Reporter AB 1207 that expires on 08/23.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RODRIGUEZ, TERE	FACILITY NUMBER: 394500091
	VISIT DATE: 09/21/2021

NARRATIVE

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LPA discussed the California Child Care Worker: Mandated Reporter Training with the licensee. The licensee must complete the training every two years starting January 1, 2018 and retain proof of completion in the facility file. The training can be found at: mandatedreporterca.com. Licensee and staff have certifications.

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

Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

LPA advised the facility to follow all the Covid precautions while providing care for children.

Licensee 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.

LPA discussed the safe sleep regulations with licensee Tere 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. LPA 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.

Title 22 Deficiencies observed in the areas of today's facility evaluation are listed on 809D page. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Tere Rodriguez.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2021 05:43 PM - It Cannot Be Edited

Created By: Aruna Sridharan On 09/21/2021 at 05:14 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RODRIGUEZ, TERE	FACILITY NUMBER: 394500091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 8 children which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2021
	Plan of Correction
1 2 3 4	Licensee will have the signatures of parents on the forms and PM 286 completed and show proof of completion to LPA by POC date.

Type B

Section Cited

CCR

102425(c)(2)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 infant which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2021
	Plan of Correction
1 2 3 4	Licensee will email LPA proof of completion of LIC 9227 by POC date.

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:

Justin L Denton

LICENSING EVALUATOR NAME:

Aruna Sridharan

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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