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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004484
Report Date: 06/07/2019
Date Signed: 06/07/2019 04:15:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RODRIGUES, MICHAELFACILITY NUMBER:
414004484
ADMINISTRATOR:RODRIGUES, MICHAELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 245-7819
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:14CENSUS: 9DATE:
06/07/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Licensee, Michael RodriguesTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Michael Rodrigues. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is the Licensee and 2 helpers caring for 9 children ( 4 Infants 5 PreK). Licensee is within capacity limits of the License. Licensee’s home is a 2 bedroom, 2 bathroom, 1- level house. Hours of Operation are: Mon- Fri 8:00- 5:00pm. Daycare areas are: Living Room, Yard Area, Bathroom #1, Bathroom #2, Kitchen and Hallway. Off Limit areas are: Bedroom #1 and Bedroom #2. All off limit areas are properly barricaded with child safe fencing. LPA observed the following: Day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. Home has ample lighting and ventilation throughout. Home has a cellphone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. LPA inspected yard for health and safety hazards. LPA observed yard area toys and play structure are in good working condition. There are no poisons, detergents, cleaning products, or sharp objects accessible to day-care children. Licensee stated there are no guns or weapons in the home. Licensee’s cardiopulmonary resuscitation certifications expires:03/2020. Licensee conducted last emergency drill on 03/2019 and is properly logged. Licensee provides daily snacks for children in care. All required postings are properly posted next to the main door. Licensee has a pet dog in the home. Licensee stated pet dog is vaccinated.

LPA reviewed children’s files and facility roster during today’s visit. LPA observed facility roster and children’s files all complete and up to date.

Continue to Page 2. . .
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RODRIGUES, MICHAEL
FACILITY NUMBER: 414004484
VISIT DATE: 06/07/2019
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During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2019
LIC809 (FAS) - (06/04)
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