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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700504
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:15:16 AM

Document Has Been Signed on 06/10/2021 11:15 AM - 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:SERMENO RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
197700504
ADMINISTRATOR:LEYLA SERMENO RODRIGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 583-2059
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
06/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Leyla Sermeno RodriguezTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) King-Lewis conducted an in person Prelicensing Inspection with Applicant Leyla Sermeno Rodriguez, who guided analyst on a tour of the facility. This is a single story 3 bedroom, 2 bathroom home with living room, family room, dining room, office, kitchen, attached garage/laundry area and rear yard. There is no in ground or above ground pool/spa on the premises. There is a blow up pool properly stored in the rear-yard. Family members residing in the home include two adults (Applicant and Spouse) and 2 children (under 10 years of age). Days/hours of operation will be 5 days a week, Monday through Friday from 5:30 AM to 5:30 PM. Incidental Medical Services (IMS) policy was discussed, informing applicant when any IMS is provided, a plan for providing IMS must be submitted to the Department prior to providing care to a child that need IMS. The plan shall state the type of IMS the facility will be offering, stating the person providing care has been trained to provide the named IMS. The plan will also provide the steps that will be taken when IMS is provided to a child.

The following information regarding ADA was discuss and the following information 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

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SERMENO RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700504
VISIT DATE: 06/10/2021
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Applicant was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation.

Applicant was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

Applicant was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Physical Plant: LPA observed the home to be clean and orderly, fireplace screened, central air and heating, age appropriate toys and play equipment, working smoke detector and carbon monoxide detector. Applicant has cameras throughout the facility. LPA discuss Health Section 1596.846(b) and (c)–102417 (g)(10) and provided applicant with a visual copy of prohibited items. LPA did not observe prohibited items during the inspection. There is a designated area for ill child(ren) as necessary. Applicant stated no weapon/firearms in home, facility sketch completed, the off limit area are the office, kitchen, master bedroom and bathroom, bedroom #2 and garage. Applicant states a land line telephone and cell phone will be available and charge during daycare hours. LPA observe a fully charge 2A10BC fire extinguisher during the inspection. Applicant made poisons, medication and cleaning items inaccessible to children.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SERMENO RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700504
VISIT DATE: 06/10/2021
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Kitchen: The following are inaccessible: Sharp items, lighter, and cleaning items. LPA discuss with applicant food shall be properly stored or refrigerated in container that are labeled with child’s name when supplied by parent.

Bathroom accessible to children: The following are inaccessible: shampoos, mouthwash, medication, perfumes, razor, air freshener, nail polish and polish remover. LPA observed a clean, safe and operable Toilet and faucet.

Outdoor: LPA observed the play area to be clear of hazard, no garden tools, poisonous plants, thorn trees cactus, or lawn mower accessible to children. play area is fenced and gated all around, no body of water on the premises, blow up pool empty and properly stored. LPA did not observer any pets.

Advisory/Other: LPA observed a first Aid kit with emergency supplies and a thermometer. Applicant’s CPR/First Aid expires 01/24/2022. Preventative Health & Safety completed 05/27/21. LPA advise to always make sure all electrical outlets are inaccessible to children. LPA observed mats for children to use for naps.

Documents Provided and or Discussed: The following were provided to comply with Title 22 requirements: Fire Drill Log, roster, Safe Sleep poster, water lead poster, required postings and list of CCL forms required for child file for each child in care. LPA observed the Lead Information Flyer posted. Applicant stated she plan to have child care insurance once she receives the facility license. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

Applicant stated at this time no transportation is offered.

Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SERMENO RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197700504
VISIT DATE: 06/10/2021
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Application Documents: Applicant file is complete with required documentation.

During this inspection, the facility was observed to be in compliance with Title 22. The application for a large Family Child Care Home with a maximum capacity of 012 or 0014 with parent notification will be submitted for approval.

An exit interview was conducted, and a copy of this report was provided to the applicant on this date.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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