274416029-9-7-2022-07-CC-FCJO-CJ2RQ8-20220907131306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274416029
Report Date: 09/07/2022
Date Signed: 09/07/2022 07:55:05 PM

Document Has Been Signed on 09/07/2022 07:55 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	RODRIGUEZ, JACQUELIN		FACILITY NUMBER:	274416029
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	09/07/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jacquelin Rodriguez		TIME COMPLETED:	01:20 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	Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an announced pre-licensing inspection to the home today. LPA met with Jacquelin Rodriguez, applicant, and explained the nature of today's inspection to her. Applicant states that herself, and her adult son Rodrigo David are the adults residing in the two story home. Applicant states that her minor daughters ages 16, 10, and 8 years old also reside in the home. Days and hours of operation will be Monday to Saturday from 5:00 AM to 6:00 PM. Applicant understands that the children cannot stay in the home for more than 24 continue hours. Applicant has completed her Preventative Health and Safety Child Care Training on 9/17/21, Applicant's pediatric CPR and First Aid certifications are current and will expire on 8/28/23, Applicant owns the home and a copy of mortgage bill is in file. Applicant states does not have liability insurance for a family child care home (FCCH) and will use the Affidavit regarding liability insurance for Childcare (form LIC 282). LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed there are not wall heaters in the home. LPA observed a barricaded fireplace located in the on limits living room. LPA observed barricaded stairs in the home. Off limit areas inside the home: All the second floor, one bedroom, and the attached garage. Applicant stated the laundry area is located upstairs. LPA observed applicant has a 2A10BC fire extinguisher in the home, and at least one working smoke detector. LPA observed the home has at least one working carbon monoxide detector. Off limits outdoor areas are: Only the front yard. Applicant will use the back yard as playground for the children in care. LPA observed the back yard is fenced. Applicant states that there are no weapons in the home. Applicant understands that cleaning products, toxic agents, medications, and sharp objects shall not be accessible to children. LPA reminded applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes. ******************* Report dated 9/07/22 continues in page 2 *************

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RODRIGUEZ, JACQUELIN	FACILITY NUMBER: 274416029
	VISIT DATE: 09/07/2022

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
26
27
28
29
30
31
32

Report dated 9/07/22 continues from page 1.

Forms of discipline applicant will use: Communication with children and redirection. Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options for a small license, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed applicant that fire/disaster drills must be practiced at least once every 6 months and documented. A Family Child Care Home packet with updated Licensing forms was provided to and reviewed with the applicant. Department website: www. ccld.ca.gov provided to applicant. Applicant understands that children residing in the home count as part of the capacity until them reach the age of ten years old.
LPA discussed the requirements of AB 633 with the applicant. LPA also discussed "zero tolerance" related regulations with the applicant.
LPA observed proof of immunization for measles, pertussis and influenza are in the applicant's file.

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.
Applicant has completed the required "mandated reporter" training AB1207 on 8/14/21 and applicant understands the training is mandatory for all the adults in contact with children, and to be renewed every two years. LPA referred the applicant to the training website: www.mandatedreporterca.com for additional information on the online training.
A review of staff records on 9/06/22 indicates that all the adults residing in the home or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Applicant states that Manuel Vazquez will not reside in the home , and does not have any interest in residing in the home. Applicant has submitted a copy of the Quit Claim Deed showing Manuel release and forever quitclaim to Jacquelin.

**************************Report dated 9/07/22 continues on page 3**********************

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RODRIGUEZ, JACQUELIN	FACILITY NUMBER: 274416029
	VISIT DATE: 09/07/2022

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
26
27
28
29
30
31
32

Report dated 9/07/22 continues from page 2.

Applicant, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 applicant and discussed the Child Care Licensing Safe Sleep web page at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant, 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.

LPA reviewed with applicant, the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the applicant, Jacquelin Rodriguez.

LPA conducted an exit interview with the applicant and she was informed that a small FCCH license will be approved pending on the following: 1) Applicant will submit a new sketch of the home showing the correct location of the garage and a bedroom which are off limits, and 2) Approval from a manager of the Licensing Department.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3