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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628204
Report Date: 12/07/2021
Date Signed: 12/07/2021 04:11:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:RODRIGUEZ, MAYRA & WILFREDO FAMILY CHILD CAREFACILITY NUMBER:
376628204
ADMINISTRATOR:MAYRA & WILFREDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 305-5400
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:14CENSUS: 10DATE:
12/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Mayra RodriguezTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/07/2021 at 3:15 PM Licensing Program Analyst (LPA), Dana Stevens, conducted an unannounced case management visit for the purpose of citing a violation observed during a complaint investigation. Ten children were present at the time of the inspection.

During inspection of the facility LPA observed a day care child napping in the off-limits master bedroom.

Licensee 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.

Deficiencies are cited on the attached LIC 809D.

Exit interview was conducted and copy of report was provided to Licensee.
Notice of site visit must be posted for 30 days.
SUPERVISOR'S NAME: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RODRIGUEZ, MAYRA & WILFREDO FAMILY CHILD CARE
FACILITY NUMBER: 376628204
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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1012416.3(a)(6) Prior to making alterations or additions to a family child care home... licensee shall notify the Department of the proposed changed, including... (6) Any change from an area... previously identified as "off limits" to an area where care and supervision will be provided...
This requirement was not met as evidenced by:
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Based on LPA observation, the licensee did not comply with the section cited above by not ensuring the off-limits room was inaccessible, which poses/posed a potential health, safety or personal rights risk to persons 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: Cynthia GrayTELEPHONE: (619) 767-2258
LICENSING EVALUATOR NAME: Dana StevensTELEPHONE: (619) 767-2238
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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