566208795-4-5-2021-17-CC-BCES-BZSURJ-20210405154848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 566208795
Report Date: 04/05/2021
Date Signed: 04/05/2021 03:49:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	RODRIGUEZ FAMILY CHILD CARE		FACILITY NUMBER:	566208795
ADMINISTRATOR:	CARMEN RODRIGUEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 231-8213
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	14	CENSUS: 10	DATE:	04/05/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Carmen Rodriguez		TIME COMPLETED:	04:00 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	On April 5, 2021 at 2:40 PM, Licensing Program Analyst (LPA) Betzayra Cervantes conducted an unannounced tele-inspection for the purpose of completing a Case Management - Incident inspection. Due to COVID-19 and Department of Public Health guidelines of social distancing a Tele-Inspection was conducted via Facetime. LPA met with Licensee Carmen Rodriguez and advised her the purpose of the inspection. LPA and licensee conducted a tour of the facility and observed 10 children in care at the time of the inspection. On 3/11/2021, the facility self reported an incident where at around 8:15AM, Child #1 (C1) was playing in the main playroom on a soft infant slide. Licensee stated that normally the slide is placed outside in a designated area for the children, but on the date of the incident she had moved it inside due to it being a windy day. Licensee was caring for four children at the time of the incident. C1 and C2 were playing together on the slide, C3 was reading a book in another part of the room, and C4 was getting his hands washed in the bathroom by the licensee. Licensee explained that while washing the hands of Child #4 in the bathroom which is located within view of the playroom, she heard C1 talking. Licensee explained that she turned to look at him and observed C1 standing at the top of the slide proceed to fall backward and hit the back of his head on a small wooden shelf resulting in a cut, causing it to bleed. C1 cried out and licensee immediately went over to the child. LPA observed the area where the incident occurred and observed that there was no slide present, however, a wooden shelf which appears to be 2 feet tall comprising of plastic containers filled with plastic building blocks. Licensee immediately went to the child and provided first aid by applying pressure with a paper towel, to stop the bleeding. Licensee immediately called parent and parent arrived shortly at 8:30AM and took C1 to the doctor. C1 received 2 staples to the back of the head and returned to care on 3/15/21. There were no restrictions required by the doctor. Licensee advised the child has been doing well and playing with the other children. Continued on 809-C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra Cervantes	TELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE	FACILITY NUMBER: 566208795
	VISIT DATE: 04/05/2021

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Interview with licensee also revealed that there have not been any injuries in the past involving the play equipment. She stated that the slide was removed the day of the incident on 3/11/21 as a precautionary measure.

Given the licensee's account of the incident when reported to Community Care Licensing and how they addressed the incident, LPA deemed licensee's action was appropriate.

No deficiencies were cited during today's visit.

Exit interview conducted with licensee Carmen Rodriguez. A copy of this report was reviewed and provided to the licensee via email. The delivered/read receipt confirmation from email will be in lieu of the signature once she received the report.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Betzayra Cervantes	TELEPHONE: (805) 680-7175
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC809 (FAS) - (06/04)

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