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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009956
Report Date: 05/01/2024
Date Signed: 05/01/2024 02:44:58 PM

Document Has Been Signed on 05/01/2024 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:RODRIGUEZ, KYLEE FCCHFACILITY NUMBER:
233009956
ADMINISTRATOR/
DIRECTOR:
RODRIGUEZ, KYLEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 489-3499
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 14TOTAL ENROLLED CHILDREN: 26CENSUS: 11DATE:
05/01/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:06 AM
MET WITH:Kylee RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:58 PM
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A Required Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 4/8/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During today’s inspection the home and grounds were toured. The Licensee was supervising 11 children and was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicles. The facility’s operating hours are from 7:45 AM - 2:45 PM Monday, Wednesday, and Friday and 8:30 AM - 1:30 PM on Tuesdays and Thursdays. The facility was toured inside and outside and the floor and yard plans submitted by the licensee were verified. The children will have access to the office, main classroom, the front yard, the backyard, and student bathroom. The "off limits" areas include the home's master bedroom, the staff bathroom, the laundry room, the kitchen, the backyard shed, and the side yards. These areas were made inaccessible by door locks and latches. The home was at a comfortable indoor temperature. The children in care have access to age-appropriate toys and equipment. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification was current and expires in June 2025. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke detector, carbon monoxide detector, and a fully charged fire extinguisher rated at least 2A10BC. The Licensee stated that no firearms are stored in the facility which was observed by the LPA. LPA observed that there were poisons stored in the backyard shed which was unlocked.


Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RODRIGUEZ, KYLEE FCCH
FACILITY NUMBER: 233009956
VISIT DATE: 05/01/2024
NARRATIVE
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The regulation that poisons are to be locked using a key or combination lock was reviewed. There is no spa, pool, pond, or fountain observed on the premises and none shall be added without prior approval of the Licensing agency. The Licensee stated that she has not conducted a disaster drill within the last six months. The facility roster of the children in care was reviewed and appeared to be complete. LPA reviewed staff and personnel records at 11:37 AM which revealed that the licensee did not possess a current mandated reporter training certificate, staff 2 (S2) did not possess a current tuberculosis clearance and proof of immunization against measles. LPA reviewed five children's records (C1-C5) at 12:29 PM which contained all records as required.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.



Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: RODRIGUEZ, KYLEE FCCH
FACILITY NUMBER: 233009956
VISIT DATE: 05/01/2024
NARRATIVE
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On this date, 04/30/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. During the exit interview, the Licensee Kylee Rodriguez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.



Exit interview conducted and report was reviewed with Licensee Kylee Rodriguez. 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. The following violations of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/01/2024 02:44 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/01/2024 at 01:39 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RODRIGUEZ, KYLEE FCCH

FACILITY NUMBER: 233009956

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the backyard shed containing poison was unlocked which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee stated she would create a sign to remind her to ensure the shed door is locked at all times when children are present and send LPA a picture of the posted sign by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not complete a disaster within the last 6 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee stated she would conduct a disaster drill on 5/2/24 and send LPA a copy of th updated disaster drill log on 5/3/24.
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/01/2024 02:44 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/01/2024 at 01:39 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RODRIGUEZ, KYLEE FCCH

FACILITY NUMBER: 233009956

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not possess a current Mandated Reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee stated she would obtain a current Mandated Reporter training certificate and send proof to LPA by email at robert.maciel@dss.ca.gov.
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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Based on record review,staff 2 (S2) did not possess proof of immunization against measles which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee stated she would ensure S2 obtains proof of immunization against measles and send proof to LPA by email at robert.maciel@dss.ca.gov.
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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/01/2024 02:44 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/01/2024 at 01:40 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RODRIGUEZ, KYLEE FCCH

FACILITY NUMBER: 233009956

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, staff 2 (S2) did not possess a current tuberculosis clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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2
3
4
Licensee stated she would ensure S2 obtains a tuberculosis clearance and send proof to LPA by email at robert.maciel@dss.ca.gov.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
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