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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700059
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:04:16 PM

Document Has Been Signed on 10/12/2022 03:04 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:RODRIGUEZ, YSGLEEFACILITY NUMBER:
015700059
ADMINISTRATOR:RODRIGUEZ, YSGLEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-3779
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 14TOTAL ENROLLED CHILDREN: 19CENSUS: 13DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Ysglee RodriguesTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/12/2022 at 10:09am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Ysglee Rodriguez for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her sister Ysabel Rodriguez and her mother Isbelia Delgado De Rodriguez who are both her helpers. There were three (3) school age child, seven (7) preschool age children and three (3) infants present during the inspection. Licensee lives in the home with her mother and two minor children. The facility currently operates 24 hours a day, 7 days a week.

ON LIMITS AREA: Entire 2nd floor (Family Room, Living Room, Kitchen, Dining Room, Bathroom and Bedroom) and Backyard
OFF LIMITS AREA: Entire 1st floor and 3rd floor
ISOLATION AREA: Bedroom or living room

The facility is a three-story home rented by the Licensee. The inside and outside of the home were observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee provides all food for the children in care. Any food brought from the children’s home will be properly stored and labeled. Licensee stated there are no firearms and no pets in the home.

Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059
VISIT DATE: 10/12/2022
NARRATIVE
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The home has one (1) fully charged 3A40BC fire extinguisher in the kitchen. There is one (1) working smoke/carbon monoxide detector in the hallway by the dining room, the bedroom, and in the hallway by the bathroom. The staircases leading to the first and third floor of the home are gated making them inaccessible to the children in care. Although the entire backyard is “on-limits,” Licensee stated that there is a portion that is not used. LPA suggested Licensee block the area of the backyard that is not used. The electric fireplace in the family room has been blocked and disconnected, making it inaccessible to the children in care. The home is equipped with central heat and air for proper ventilation. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within the licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed. Licensee and her two (2) helpers Pediatric CPR and First Aid training is complete and expires 6/2023. Licensee’s Mandated Reporter training is complete and expires 11/7/2023. Fire and disaster drill log is complete with last drill logged 8/18/2022. All required postings are made visible by the front door of the home. All adults living and working in the home have obtained a cleared criminal record clearance. LPA obtained the facility files, helpers files and children’s files. During LPA’s record review it was found that out of the thirteen (13) files reviewed only five (5) children’s files were complete.

Deficiencies Sited During Inspection
· Two (2) children missing files and Four (4) children are missing LIC627: Consent for Emergency
Medical Treatment
· Four (4) children were missing LIC995A: Parents Rights
· Five (5) children missing Immunization Records

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.
Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059
VISIT DATE: 10/12/2022
NARRATIVE
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Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.

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.

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. 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.

Continued on LIC809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059
VISIT DATE: 10/12/2022
NARRATIVE
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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.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with Licensee Ysglee Rodriguez.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2022 03:04 PM - It Cannot Be Edited


Created By: Morgan Pringle On 10/12/2022 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review 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: 10/12/2022
Plan of Correction
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4
Deficiency was cited in error by LPA. Deficiency was cleared during inspection. Appeal process was explained to Licensee during inspection.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited abovewhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee will submit proof of completed files for 2 children with missing files. Licensee will send LPA proof of missing LIC627 for 4 children. Licensee will send a statement stating how she will make sure she receives completed documents before a child's first day.
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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2022 03:04 PM - It Cannot Be Edited


Created By: Morgan Pringle On 10/12/2022 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 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: 10/14/2022
Plan of Correction
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4
Licensee will send LPA proof of missing LIC995A for 4 children.

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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2022 03:04 PM - It Cannot Be Edited


Created By: Morgan Pringle On 10/12/2022 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: RODRIGUEZ, YSGLEE
FACILITY NUMBER: 015700059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, 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: 10/14/2022
Plan of Correction
1
2
3
4
Licensee will send LPA proof of missing Immunization record for 5 children.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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