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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004828
Report Date: 08/18/2021
Date Signed: 08/18/2021 03:35:26 PM

Document Has Been Signed on 08/18/2021 03:35 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RODRIGUEZ, CONSEPCIONFACILITY NUMBER:
414004828
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Rodriguez ConsepcionTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kaur met with Applicant Rodriguez Consepcion, for an announced pre-licensing inspection today at this facility. This is a two-story single-family home. The Applicant rents the house, and property control was in the file with licensing. All documents obtained from the Applicant had been reviewed and met the Department's requirements. The Applicant states that 4 adults live at home — the Applicant, her husband, 2 sons. The entire house is inspected for health and safety hazards. Days and operations are Monday – Friday from 7 AM – 6 PM.

LPA and the Applicant inspected the entire home for Health and Safety Hazards. The house consists of 3 bedrooms, 1/1/2 bathrooms, a living room, dining room, kitchen, three bedrooms, and backyard. Daycare areas are the living, kitchen, backyard and bathroom #1. Off-limit areas 2nd floor, bedroom on 1st floor and garage. There is child gate installed in living room to prevent access. All toxic or dangerous materials are stored in cabinets with child protective locks installed, making them inaccessible to children. The use of baby-gate barricades all off-limit areas. Per Applicant, there are no firearms, weapons in the house. Licensee has dog. The isolation area for sick/ill children will be corner of living room. The house has multiple combinations of smokes & carbon monoxide detectors.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RODRIGUEZ, CONSEPCION
FACILITY NUMBER: 414004828
VISIT DATE: 08/18/2021
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The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com. The Applicant was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Also discussed were the IMS (Incidental Medical Service) policies. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/childqanda.htm


Prior to licensure, the following issue must be addressed.
- The Applicant, her husband and 1 son fingerprint clearance pending.
- Install Child lock in kitchen drawers and cabinets.

The report was reviewed and signed by the Licensee, Rodriguez Consepcion. Today's report, 08/18/2021, and notice of site visit will be sent to the Licensee ramirezconnie22@gmail.com by the close of business on 08/18//21. Confirmation of receipt is required.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Harsimran Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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