013422861-5-16-2022-52-CC-MPRE-CEGSS2-20220516140713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422861
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:07:32 PM

Document Has Been Signed on 05/16/2022 02:07 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	VAZQUEZ DE RODRIGUEZ, KARINA		FACILITY NUMBER:	013422861
ADMINISTRATOR:	VAZQUEZ, KARINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(702) 339-1444
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	14	CENSUS: 6	DATE:	05/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Karina Vazquez de Rodriguez		TIME COMPLETED:	02:04 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 5/16/2022 at 11:25am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Karina Vazquez de Rodriguez for an Unannounced Annual Inspection. Present during the inspection was three (3) infants, one (1) preschool age child and two (2) school age children. One (1) infant and one (1) school age child belongs to the licensee. Licensee lives in the home with her criminal record cleared husband, their twelve (12) and one (1) year old daughters and their eight (8) year old son. All adults living in the home and in the studio on the property have obtained a criminal record clearance. The tenant in the studio has no access to the home. The facility operates 6:00am – 6:00pm, Monday - Friday. ON LIMITS AREA: Living Room, Kitchen, Playroom, All Three (3) Bedrooms, Two (2) Bathrooms and Backyard OFF LIMITS AREA: Studio and Garage ISOLATION AREA: Living Room The facility is a single-story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms no pets in the home. The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen. There is a working carbon monoxide detector in the kitchen. There is a working smoke detector in the playroom. There is a working wall heater in the hallway that has been barricaded and made inaccessible to the children in care. The home is equipped with many windows for proper ventilation. LPA did not observe any harmful bodies of water in or around the home. Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VAZQUEZ DE RODRIGUEZ, KARINA	FACILITY NUMBER: 013422861
	VISIT DATE: 05/16/2022

NARRATIVE

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The Licensees Health and Safety training has been completed. Licensees Pediatric CPR and First Aid training is completed and expires 1/22/2024. Licensees Mandated Reporter training is current and expires 7/6/2023. Fire/disaster drill log is complete with the last drill held on 4/5/2022. All required forms are posted and visible for public view in the hallway by the front door. LPA obtained the children’s files and facility roster.

· All infants under the age of one (1) was missing LIC9227: Individual Infant Sleeping Plan and all infants are missing a sleep log (See LIC9102TV). LPA Pringle gave technical assistance on Infant Safe Sleep during inspection as well.
· Assistant is missing three (3) forms in file and immunization record (See LIC9102TV).

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: VAZQUEZ DE RODRIGUEZ, KARINA	FACILITY NUMBER: 013422861
	VISIT DATE: 05/16/2022

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

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 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee Karina Vazquez de Rodriguez

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC809 (FAS) - (06/04)

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