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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700191
Report Date: 08/13/2021
Date Signed: 08/13/2021 11:37:21 AM

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:DUNN, RODEEN FAMILY CHILD CAREFACILITY NUMBER:
197700191
ADMINISTRATOR:DUNN, RODEENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 878-6794
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:14CENSUS: DATE:
08/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Rodeen DunnTIME COMPLETED:
11:45 AM
NARRATIVE
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On August 13, 2021 ay 09:31am Licensing Program Analyst (LPA) Zirbes and Heath conducted an unannounced case management inspection. The purpose of the case management was to cite for deficiencies observed. LPA's met with the Licensee to discuss the case management.

On August 13, 2021 at 8:49am LPA Zirbes observed a play yard in the bedroom 3, infant room. Inside the play yard, laying on the fitted sheet, LPA observed a Smiling Gaia baby accessory The Smiling Gaia was approximately 3 feet long, 2.5 feet wide, and 3.5 inches high. In addition, LPA observed a baby bottle and bib inside the crib and a blanket laid over the side of the crib. An infant was not in the crib at the time of LPA Zirbes observation.
During the inspection, LPA Zirbes and Heath interview staff 2 (S2) refer to confidential names list LIC 811 dated August 13, 2021. S2 expressed the play yard is utilized by child 1 (C1). S2 stated the additional play yard accessory was provided by C1's mother. According to S2, when C1 is placed down for a nap, C1 is placed on the Smiling Gaia padded accessory inside the playpen. LPA Zirbes provided S2 with a safe sleep flyer during the conversation. LPA Heath reviewed C1's file, and observed the file did not contained medical documentation regarding C1 sleeping on the Smiling Gaia baby accessory. During the inspection, LPA's also spoke with the Licensee regarding the Smiling Gaia baby accessory. Licensee stated C1's mom provided the Smiling Gaia baby accessory which has been used when C1 sleeps in the play yard.
During this inspection, LPA Zirbes observed the Smiling Gaia baby accessory was removed from the play yard . LPA Zirbes observed C1 napping in a bare environment playpen.
A deficiency is being cited based on LPA's observation, record review and interviews in accordance, with California Code of Regulations, Title 22, see LIC 809D.
An exit interview was conducted and Plan of Correction were reviewed and developed with the Licensee. LPA's provided Licensee with PIN 17-03-CCP and the website to the CDSS Safe Sleep in Child Care information. A copy of this report wand appeal rights were discussed with the Licensee.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: DUNN, RODEEN FAMILY CHILD CARE
FACILITY NUMBER: 197700191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited

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102425 Infant Safe Sleep (b) Cribs or play yards shall be free from all loose articles and objects.
This requirement is not meet as evidenced by:
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Based on LPA's observation, and interviews, a Smiling Gaia baby accessory was an additional object/loose article placed inside the playpen C1 took naps in. This posses a potential risk to the health and safety of the children in care.
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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: Carissa BellTELEPHONE: (661) 202-3359
LICENSING EVALUATOR NAME: Kendal ZirbesTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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