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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483002086
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:44:47 PM


Document Has Been Signed on 03/29/2023 02:44 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: 7DATE:
03/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Adela Baca Rodriguez - LicenseeTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Melchisedeck Augustin made an unannounced case management visit to verify that an adult (A1) without an approved criminal record and child abuse index clearance or exemption was not present at the facility. On 12/09/22, the facility was cited a type A deficiency because the Licensee, Adela Baca Rodriguez (LS) did not ensure an adult (A1) obtained a criminal record and child abuse index clearance or exemption prior to residing in the home, and Department records confirmed A1 had not obtained a criminal record clearance or exemption. During the visit, LPA met with LS and discussed the purpose of the visit. There were seven daycare children present and the children did not appear to be in distress. LS agreed to allow LPA to take a tour of the facility’s off limit areas which consisted of three bedroom on the first floor, and two bedrooms and an office on the lower floor. During the tour, LPA did not see A1 in any of the off-limit areas and based on LPA’s observations, A1 was not present at the facility. LS claimed A1 and all item(s) belonging to A1 were moved out of the facility on 03/24/23, and LS provided current residence and mailing address for A1.

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 $3000.00 maximum per day/per person will be assessed if this regulation is violated.

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. There were no violation(s) of the California Code of Regulations, Title 22; Division observed or cited during today’s visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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