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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621883
Report Date: 11/19/2020
Date Signed: 11/19/2020 10:56:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:RODRIGUEZ, ANGELINAFACILITY NUMBER:
343621883
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
11/19/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelina RodriguezTIME COMPLETED:
10:45 AM
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NOTE: Due to Covid-19 and DPH guidelines on physical distancing, a Tele-visit via Google Duo was conducted. On Thursday, November 19, 2020, at 09:00 AM, Licensing Program Analyst (LPA) Elvira Sierra conducted an announced increase of capacity tele-inspection and met with Licensee, Angelina Rodriguez. Facility operates Monday- Friday from 06:00 AM to 12:00 AM. Census today is 5 children ( 1 preschool, and 4 school age). Licensee understands that children residing in her home 10 years or younger will enter in her capacity if present. Fire Safety Inspection Clearance was granted on 11/17/20 for a total capacity of 14 children. All individuals residing in the home have obtained a criminal record clearance.

A health and safety inspection was conducted inside and out. This facility is a one story home with 4 bedrooms and 2 bathrooms. The off-limit areas in the home will consist of; All bedrooms, Garage, portion of the backyard, front yard and driveway. Fire extinguisher, smoke and carbon monoxide detectors meet regulation. Sharp knives are stored in the garage. Toxins and cleaning supplies are inaccessible to the children. Toys appear to be safe and appropriate for children in care. Licensee stated that there are no weapons in the home and no bodies of water. The facility currently does not provide Incidental Medical Services – IMS. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family childcare home evaluator manual (FCCH EM) Policy 102417.A current CPR/First Aid was verified and expired on 03/15/21. Mandated Reporter Training was verified and expires on 02/26/22. LPA reviewed large family childcare home capacity limitations with licensee. Safe Sleep in Child Care, the Effects of Lead Exposure brochures, COVID-19 Posting documents and the use of Personal Protective Equipment during COVID-19 Outbreak guidance were observed in the home. Self Assessment checklist was received.

As of today's date, facility is licensed to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or elementary school and 1 child at least age 6 with a maximum of 3 infants. No deficiencies were observed in today's tele-visit. In lieu of Licensee's signature, LPA is e-mailing the report with a read receipt request to Licensee. Notice of Site Visit was email to Licensee. Notice of Site Visit should be posted in a conspicuous area for 30 days.Please note: When a physical inspection takes place, requests for alterations may be made.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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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