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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198006680
Report Date: 06/26/2019
Date Signed: 06/26/2019 10:55:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
198006680
ADMINISTRATOR:RODRIGUEZ,ANDREAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 962-9286
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY:14CENSUS: 4DATE:
06/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Andrea RodriguezTIME COMPLETED:
11:05 AM
NARRATIVE
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An unannounced Random Inspection was conducted by Licensing Program Analyst (LPA) Jennifer Hua. LPA met with licensee Andrea Rodriguez who guided LPA on a tour of the facility. This is a single story, four bedroom, two bathroom home. Currently residing in the home are total 3 adults (Licensee and adult son Robert Rodriguez, Licensee's brother Juan Orozco. Licensee is Spanish speaking but speaks little English. Licensee's son was present and served as translator.

Areas accessible to children were inspected as follows: Play room that has its own entrance, dining room, one bathroom and front yard.

Areas off limits include: Kitchen, formal dining area, living room, all four bedrooms, one bathroom, and the back yard where dog is housed.

Licensee states that there are no weapons or firearms on the premises. LPA did not observe swimming pools or spas or bodies of water on the premises. The front yard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors and carbon monoxide detectors are present in the facility. The fire extinguisher is fully charged but has not been serviced annually.

—Licensee's Pediatric First Aid/CPR Card valid until: 5/4/21.
—Child Care Roster, Disaster Plan, and Children's Records were reviewed and discussed. Liability Insurance policy in place and will expire on 5/13/20.
—Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal record clearance requirement. Licensee was informed to complete the Mandated Reporter Training on department website at http://www.mandatedreporterca.com/ when it is available in her language.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198006680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2019
Section Cited
CCR
102417(g)(1)
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Operation of a Family Child Care Home. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. The requirement is not met as evidenced by: LPA observed fire extinguisher is fully charged but has not been serviced annually. This poses a potential risk to the health & safety of children.
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Per licensee, will purchase a new fire extinguisher and submit copy of receipt and photo to LPA by the POC due date of 7/1/19
Type B
07/01/2019
Section Cited
CCR
102418(g)(1)
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Immunizations. The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after
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Per licensee, correct and will maintain copy and submit copies to LPA by the POC due date of 7/1/19
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enrollment in the family day care home. The requirement is not met as evidenced by: LPA observed 2 files need record and 1 file need updates. This poses a potential risk to the health and safety of children in care.
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Type B
07/10/2019
Section Cited
HSC
1596.7995(c)
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Immunization Requirements. Effective 9/1/16, all individuals who provide care and supervision to children are required to obtain immunizations for Pertussis, Measles and Influenza. Records not available for licensee
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Per licensee, will correct and maintain record and submit copy to LPA by The POC due date of 7/10/19.
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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 198006680
VISIT DATE: 06/26/2019
NARRATIVE
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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

The following was discussed with the Licensee:
Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills were conducted on 3/2019. Smoking is prohibited in a family child care home.

Baby walkers, saucer chairs, bouncers, johnny jumpers or any similar items are prohibited. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. A Child Care Provider's Guide to Safe Sleep was provided and explained.

· Dog(s) and/or pets should be isolated from children in care.
· It is recommended that First-Aid kits be available on premises.
· Outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

These forms, updates and Title 22 Regulations may also be downloaded from our website: www.ccld.ca.gov

Deficiencies cited on attached 809D.

Exit interview was conducted with license and her son, copy of report was given. Appeals Rights provided. Notice of Site Visit Form was provided and explained.
SUPERVISOR'S NAME: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3