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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414722
Report Date: 07/08/2022
Date Signed: 07/11/2022 10:19:51 AM


Document Has Been Signed on 07/11/2022 10:19 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:
197414722
ADMINISTRATOR:RODRIGUEZ, JUANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 365-2879
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY:14CENSUS: 2DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Juana Rodriguez, Licensee TIME COMPLETED:
03:20 PM
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On 06/06/22 Licensing Program Analysts (LPAs) Justeene Tamayo and Barbara Beneroso met with Licensee, Juana Rodriguez, who guided analyst on a tour of the facility for the One Year Required inspection. This is a one story, 3 bedroom, 2 bathroom home with kitchen/dining, family room, living room, laundry room, and garage. There is no pool/spa or body of water on the premises. Upon arrival LPAs observed 1 infant and 1 preschool age child in care. Family members residing in the home include 2 adults (licensee, licensee's daughter) and one minor child. Facility operation are Monday-Friday 6:30AM-11:30PM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is provided in the living room. Children use the bathroom in hallway on the left. Children have access to the living room and bedroom #1 (nursery room). Per licensee, infants have been staying in the living room due to she only has one infant enrolled at this time. Off limit areas include all bedrooms (except bedroom #1), bathroom #2, kitchen/laundry area and garage (has a key lock door knob). The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (in master bedroom with self-latch lock and key lock), medicines (in upper kitchen cabinet) and hazardous items (sharp knives in kitchen drawer with safety latch) that can pose a danger to children. LPAs did not observe a fireplace in the home. Safe and age appropriate toys, play equipment and materials. LPAs observed a fire extinguisher (1A10BC) in the home . LPAs advised licensee will need to purchase the required fire extinguisher that meets the Fire Marshal Standards, either a 2A10BC or 3A40BC and email a picture to LPA Tamayo for proof of correction. Facility has been cited a Type B Citation. Please see LIC 809-D
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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: 197414722
VISIT DATE: 07/08/2022
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The smoke detector and carbon monoxide detector are in operable condition. Per Licensee no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/ play equipment were observed on the premises. There is a designated area for ill children as necessary in the nursery room. Per Licensee there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (landline and cell).

Fire/earthquake drills are maintained current. Last fire/duster drill was completed on 03/14/2022. Roster complete and maintained current.

Bathroom: Shower/tub are free of hazards (child care bathroom). LPAs did not observe any hazardous items in the children's bathroom. Toilet and faucet are clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are in master bedroom(off limit with key lock and latch lock). Breakfast, lunch, snacks and dinner are provided. Licensee currently has a food program. Naps are provided in the main care area (living room)

Outdoor: The front yard is safe for children. LPAs observed play equipment in the front yard, as well as safety cones in the openings of the front yard. Per licensee, she supervises the children during outdoor play at all times, and plans to build a front gate in front of the house. There is no body of water. LPAs observed age appropriate toys. Per licensee, there are no pets on the premises.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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: 197414722
VISIT DATE: 07/08/2022
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Advisory/Other: First Aid kit was observed with supplies readily available. CPR/First Aid expire 05/01/2023. Mandated Reporter expired 02/25/2022. LPAs advised licensee will need to retake the mandated reporter training at www.mandatedreporterca.com and email to LPA Tamayo for proof of completion no later than today 07/08/2022. There are no window cords accessible to children.

Licensee stated unaware of the new Safe Sleep Requirements. After children file review, LPAs did not observe an individual sleeping plan (LIC 9227) or a safe sleep log that documents infants sleep patterns every 15 minutes. LPAs gave licensee copies of the LIC 9227 and Safe Sleep Log and reminded licensee of Safe Sleep Regulations. Facility has been cited two Type B Citations. Please see LIC 809-D.

Documents Provided and or Discussed: Safe Sleep Chart (Every 15 minute Check), Individual Sleeping Plan (LIC9227), and Safe Sleep PIN 20-24-CCP. Licensee stated currently does not have child care insurance.

Licensee Rodriguez 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.

LPAs discussed the safe sleep regulations with licensee 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. LPAs 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.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 197414722
VISIT DATE: 07/08/2022
NARRATIVE
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A notice of site visit was given to licensee and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee Juana Rodriguez along with her appeal rights.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/11/2022 10:19 AM - It Cannot Be Edited

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: 197414722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed a fire extinguisher 1A10BC that does not meet Fire Marshal Standards in the home, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will purchase the required fire extinguisher that meets the Fire Marshal Standards, either a 2A10BC or 3A40BC and email a picture to LPA Tamayo for proof of correction
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. After file review and interview, it was dislosed that licensee is unaware of the Safe Sleep Regulations, and has not been documents infants sleep patterns every 15 minutues, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will ensure she is documenting infants sleep patterns every 15 minutes and send a picture to LPA Tamayo for proof of correction. LPAs also went over PIN 20-24-CCP and gave a copy of the PIN and Safe Sleep Log to licensee.

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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6


Document Has Been Signed on 07/11/2022 10:19 AM - It Cannot Be Edited

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: 197414722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. After file review during the inspection, the infant enrolled in the facility did not have a completed Individual Sleeping Plan LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have the authorized representatives fill out the LIC9227 and have the completed document in infants file. Licensee will send a picture to LPA Tamayo via email for proof of completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Justeene TamayoTELEPHONE: 661-202-3796
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6