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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009956
Report Date: 06/14/2021
Date Signed: 06/15/2021 11:12:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:RODRIGUEZ, KYLEE FCCHFACILITY NUMBER:
233009956
ADMINISTRATOR:RODRIGUEZ, KYLEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 489-3499
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:14CENSUS: 10DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Kylee RodriguezTIME COMPLETED:
01:40 PM
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An annual inspection was made to the facility by Licensing Program Analyst (LPA), Mary Trinh. A review of staff records on 06/14/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently one adult living in the home.
During today’s inspection the home and grounds were toured. The licensee and Assistant were supervising 10 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7:45 am to 2:45 pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are kitchen, and were made inaccessible by child's gate. The home was clean and orderly. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 06/05/2023. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. No Poisons are kept in the home. There is no staircase as the home is a one story. There is no fireplace. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee has a current roster of children in care. The licensee has conducted an emergency drill within the past six months, last drill was conducted on 04/29/2021 and 04/30/2021.
Continued...
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: RODRIGUEZ, KYLEE FCCH
FACILITY NUMBER: 233009956
VISIT DATE: 06/14/2021
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The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The children use the backyard as the outdoor play area and it is fully fenced. There were no pools or bodies of water observed in the yard. The licensee is providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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. (10) children’s records were reviewed at 1:20 pm, and contained signed admission agreements. (3) staff records were reviewed at 1:35 pm and contained documentation of education and training as required.

The following information regarding ADA was provided: US Department of Justice 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
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