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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153911810
Report Date: 06/19/2023
Date Signed: 06/19/2023 02:01:56 PM

Document Has Been Signed on 06/19/2023 02:01 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
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:RODRIGUEZ, ELIM FAMILY CHILD CAREFACILITY NUMBER:
153911810
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Elim RodriguezTIME COMPLETED:
02:30 PM
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On 06/19/2023, Licensing Program Analyst (LPA), Gloria Reyes conducted an unannounced Annual Required Inspection and was met by Licensee, Elim Rodriguez. Days and hours of operation are Monday through Saturday, from 5:00 AM to 11:00 PM.

LPA toured the home inside and outside and no children were observed during today's visit. Current facility sketch reviewed, and Licensee confirmed that the kitchen, dining room, bathroom and living room are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of key lock. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (661) 281-5861.

LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider said that she physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness, and labored breathing. However, she was not able to provide documentation during today’s visit. Infants can be visually observed through an open door if sleeping in a separate room. Licensee was not able to provide documentation of the Individual Infant Sleeping Plan for the child in care, is not completed and not in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. See next page

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Gloria Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO SOUTH CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: RODRIGUEZ, ELIM FAMILY CHILD CARE
FACILITY NUMBER: 153911810
VISIT DATE: 06/19/2023
NARRATIVE
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area enclosed patio in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 03/22/2022. Licensee’s pediatric CPR/First Aid expires on 03/21/2024. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.

Exit interview conducted with Licensee. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Gloria Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/19/2023 02:01 PM - It Cannot Be Edited


Created By: Gloria Reyes On 06/19/2023 at 01:25 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: RODRIGUEZ, ELIM FAMILY CHILD CARE
FACILITY NUMBER: 153911810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review during today's visit, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Licensee stated she will ensure that she keeps up to date with the facility roster. Licensee to provide a copy of roster by due date 07/03/23.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review during today's visit, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Licensee stated that she will complete the LIC 9227 and provide to parent at the next admit date. Licensee said that she will comply in the future by completing the LIC 9227 for future infants enrolled. Licensee to provide a copy of the LIC 9227 for C1 by 07/23/23.
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:Duane Matsubara
LICENSING EVALUATOR NAME:Gloria Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/19/2023 02:01 PM - It Cannot Be Edited


Created By: Gloria Reyes On 06/19/2023 at 01:25 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: RODRIGUEZ, ELIM FAMILY CHILD CARE
FACILITY NUMBER: 153911810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review during today's visit, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Licensee stated she is aware of documenting the 15 minute sleep log, however could not find for C1. Licensee to provide proof of log by 07/03/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Duane Matsubara
LICENSING EVALUATOR NAME:Gloria Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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