<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483002086
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:46:11 PM


Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOMEFACILITY NUMBER:
483002086
ADMINISTRATOR:RODRIGUEZ, ADELA BACAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 644-6482
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:14CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Adeka Baca Rodriguez - LicenseeTIME COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 12/09/2022 indicates not 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 three adults residing in the home, however; one adult (A1) had not obtained an approved criminal record clearance. According to the Licensee’s (LS) statement, A1 moved into the home in September 2022, A1 resided in the home for more than five days, and LS confirmed A1 had not provided care and supervision to the children in care. Department records confirmed A1 had not obtained an approved criminal record clearance, and as such, an immediate $500 civil penalty is being assessed as a result of LS not ensuring A1 obtained an approved criminal record clearance prior to residing in the home. 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.

During today’s inspection the home and grounds were toured. The Licensee (LS) was supervising five children and the facility was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 5:00am - 6:00pm, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are three bedrooms, lower level of the home and the backyard, and were made inaccessible by door locking mechanism and slip on plastic doorknob covers.

There is a working telephone in the home. There is a functional smoke detector and carbon monoxide detector; and a fully charged fire extinguisher rated at least 2A10BC. The staircase in the hallway was barricaded by a locked door and the locked door had an audible alarm device installed. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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 9


Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's interview with LS which confirmed A1 moved into the home in September 2022 and A1 resided in the home for more than five days. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. An immediate $500 Civil Penalty was assessed due to LS not complying with criminal record clearance requirement.
POC Due Date: 12/10/2022
Plan of Correction
1
2
3
4
The Licensee instructed A1 to get Livescan and Licensee submitted A1's completed LIC 9163 LPA, prior to LPA's departure. The Licensee stated in the future, she would ensure all adult(s) obtain an approved criminal record clearance prior to working or residing in the home.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on a review of the Licensee's disaster drill log which revealed the facility had not conducted an emergency disaster drill within the past six months. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
The Licensee stated she would conduct an emergency disaster drill, document the details of the drill on a log, complete the LIC 9098, and submit the drill log and completed LIC 9098 to the Department by 12/23/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.

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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee not furnishing evidence to prove she conducted 15 minute checks while C1 napped. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
The Licensee stated she would document 14 days worth of 15 minute checks on an Infant Sleep Log as well as complete an LIC 9098, and submit the complete Infant Sleep Log along with completed LIC 9098 to the Department by 12/23/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee not furnishing a current AB 1207 Mandated Reporter Training certificate. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2023
Plan of Correction
1
2
3
4
The Licensee stated she would complete the online AB 1207 Mandated Reporter Training module at mandatedreporterca.com, and Licensee intends to submit a copy of her AB 1207 Mandated Reporter Training and General Training certificates to the Department by 01/23/20 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.2(a)(2)
Reporting Requirements
(a) The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's interview with Licensee which revealed A1 moved into the home in September 2022, however; Licensee did not submit an updated LIC 279 to notify the Department. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
The Licensee stated she would complete and submit an updated application to the Department by 12/23/22 via mail. Santa Rosa Regional Office, 1450 Neotomas Avenue, Suite 100, Santa Rosa, CA, 95405.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) 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. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on five children's (C1-C5) records reviewed at 9:33am which revealed C1 was missing LIC 627 and Immunization Record (IR) and IR not transcribed onto the CDPH 286, C4 was missing IR, and C5’s CDPH 286 was incomplete. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
1
2
3
4
The Licensee stated she would provide parents with missing licensing forms, obtain parent's signatures on the forms, obtain the children's Immunization Records (IR), and transcribe IR onto the blue CDPH 286.
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086
VISIT DATE: 12/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Licensee stated the fireplace was not utilized during the facility’s operating hours. Licensee stated she did not store any poison(s) in the home, as well as LPA did not observe any. There were no firearm(s) or other dangerous weapons stored on the premise.

Licensee did not furnish a current AB 1207 Mandated Reporter Training certificate. Licensee did not furnish evidence of negative TB clearance for A1, as well as the Licensee did not complete or submit an updated application to the Department to notify that A1 moved into the home. LPA reviewed five children’s (C1-C5) records at 9:33am which revealed C1s record was missing LIC 627 and Immunization Record (IR) and IR not transcribed onto the CDPH 286, C4 was missing IR, and C5’s CDPH 286 was incomplete.

During today’s inspection, Licensee stated there was one child (C1) under 24 months old enrolled into care, C1 was present during the visit, and Licensee confirmed she had five play yards available, of which one play yard was designated to C1. The Licensee did not furnish evidence to prove she was/had conducted 15 minutes checks while C1 took a nap. According to the disaster drill log the Licensee provided to LPA, the facility had not conducted an emergency disaster drill within the past six months. The facility roster of the children in care was reviewed and appeared to be complete. The Licensee’s EMSA approved pediatric CPR/First Aid certification expire on 04/24/23. The wooden patio deck appeared to be free of hazards and was fully fenced, and there were no pools or other bodies of water observed in the yard. LPA did not observe any baby walker(s), bouncer(s) and/or jumper(s).

The facility is not providing Incidental Medical Services (IMS) to children in care. 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. LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086
VISIT DATE: 12/09/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Licensee, Adela Baca Rodriguez. The following violation(s) of the California Code of Regulations, Title 22; Division 12 were cited during today’s inspection. Appeal Rights were provided.

LPA Melchisedeck Augustin informed licensee, Adela Baca Rodriguez that this report dated 12/09/2022 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Melchisedeck Augustin informed the licensee to provide a copy of this licensing report dated 12/09/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 12/09/2022 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODRIGUEZ, ADELA BACA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483002086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the Licensee's statement confirming A1 had not obtained evidence of negative TB clearance. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
1
2
3
4
The Licensee stated she would ensure that A1 obtain evidence of negative TB clearance and Licensee would submit evidence of A1's negative TB clearance to the Department by 12/23/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9