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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423568
Report Date: 08/31/2020
Date Signed: 09/14/2020 05:19:18 PM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:RODRIGUEZ, SILVIAFACILITY NUMBER:
013423568
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
08/31/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Silvia RodriguezTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Diana Campos met with applicant Silvia Rodriguez for an announced virtual pre-licensing inspection via FaceTime. Present for this inspection was one infant. The home was toured with applicant to conduct a Health and Safety Inspection. Per applicant hours of operation will be Monday-Friday 8:00 am to 5:00pm.

The home is a one story apartment, which is neat and clean with heating and ventilation for safety and comfort. The home consists of a living room, kitchen, 5 bedrooms, 2 bathrooms, main activity/classroom with small kitchen area, and fully fenced front yard.

The OFF LIMIT AREAS are the room immediately to the left of the child care entrance, which is used as storage for supplies and toys, the living room, the two bedrooms and bathroom that are located close to the kitchen, and the kitchen which will be inaccessible by gate, closed and/or locked doors and visual supervision at all times.

The ON LIMIT AREAS are the bathroom located directly across the child care entrance, the room adjacent to the on limits bathroom, and the room adjacent to the living room. The ISOLATION AREA will be the area close to the entry way to the child care rooms. The outdoor play area will be the fenced front yard where visual supervision will be required at all times. The outdoor play area is free from defects or dangerous conditions. There are ample age appropriate toys that are safe and appear to be clean and in good repair. There are no pools, hot tubs or any other bodies of water. LPA did not observe any hazardous materials or toxins accessible to children today.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, telephone, and fully stocked First Aid Kit.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: RODRIGUEZ, SILVIA
FACILITY NUMBER: 013423568
VISIT DATE: 08/31/2020
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The applicant’s Health and Safety training is completed and CPR and First Aid certificate is current and expires 06/23/2021. There is a wall heater located in the off limits area of the home. There is a screened fireplace located in the off limits area of the home and per applicant is never used. Per applicant, there are no firearms in the home. Per applicant there are no pets in the home. A copy of the LEASE AGREEMENT was reviewed and shows control of property. A packet of forms pertaining to the children’s files and facility files were emailed and discussed, and copies were mailed to the applicant per her request.
The applicant was reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. The applicant was reminded of the responsibility as a mandated reporter. The applicant has provided proof that the required mandated reporter training was completed on 11/12/2019.
The applicant was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to sign up to receive quarterly updates by email by sending a request to ChildCareAdvocatesProgram@dss.ca.gov. The applicant was given a copy of A Child Care Provider's Guide to Safe Sleep pamphlet and LPA discussed safe sleep practices and policy.

This home meets each of the health and safety requirements to be granted a license to operate a Family Child Care Home, on this date. This home is recommended for licensure. Applicant was reminded that compliance with all Title 22 regulations and applicable Health and Safety regulations, must be maintained at all times.

Applicant understands that a copy of this report will be mailed to her to obtain signatures in ink, and signed report must be returned to LPA within 10 days.

This report shall remain on file for 3 years. Exit interview conducted with Silvia and a copy of the report was provided.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020
LIC809 (FAS) - (06/04)
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