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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274416029
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:59:31 PM

Document Has Been Signed on 10/26/2023 12:59 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:RODRIGUEZ, JACQUELINFACILITY NUMBER:
274416029
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 1DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jacquelin RodriguezTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPA) Fermin Campos-Jaramillo conducted an unannounced annual inspection to the home today. LPA met with licensee Jacquelin Rodriguez, and explained the nature of today's inspection to her. Licensee has submitted also to this Licensing Program an application for increase of capacity. Days and hours of operation are Monday to Friday from 6:00 AM to 6:000 PM. Licensee stated that the adults that reside in the home are herself and her son David.. Also in the home resides licensee's minor children ages 17, 11 and 9 years old. Licensee was providing care to an infant today. Licensees' certifications for CPR and First Aid card is current and will expire on 7/15/25 and for her son David on 4/29/25.
Licensee has obtained a fire inspection clearance by the City of Salinas Fire Department on 10/17/23.

LPA toured the indoor and outdoor areas of the two story home during today's inspection. LPA obtained a copy of the Child Care Facility Roster and it is current. Licensee has not documented a fire drill during the last six months. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed there are not wall heaters in the home. Off limit areas in the home are: All the second floor, one bedroom and a closet in the hallway in the first floor, and the attached garage. LPA observed there are barricaded stairs in the home. Licensee understands that the use of the garage is not permitted for childcare according with the fire inspection clearance document. Off limits outside areas: The right and left side yards and front yard. LPA observed the home has a back yard and it is fenced. Licensee uses the back yard as playground.
LPA observed a fully charged 2A10BC fire extinguisher last time serviced on 10/06/23, working smoke/carbon monoxide detectors and no bodies of water.
Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Licensee stated the laundry area is located within the off limits second floor.
LPA observed Licensee has previously submitted proof of immunization for pertussis, measles and influenza according with the SB792.
***********************************Report dated 10/26/23 continues in page 2.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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Document Has Been Signed on 10/26/2023 12:59 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 10/26/2023 at 11:47 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RODRIGUEZ, JACQUELIN
FACILITY NUMBER: 274416029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 comply with the section cited above, Licensee was unable to provide a log documenting fire/disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Licensee shall submit before 11/09/23 a copy of the fire/disaster drills (log provided) to licensing Program.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee was unable to produce proof of documenting infants at sleep check ups, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Licensee shall submit to licensing Program before 11/09/23 a copy of the log documenting the infant sleep for the period 10/26/23 to November 7, 2023. Licensee will continue documenting the infants sleep until they reach the age of two years.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


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Document Has Been Signed on 10/26/2023 12:59 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 10/26/2023 at 11:47 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: RODRIGUEZ, JACQUELIN
FACILITY NUMBER: 274416029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

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 comply with the section cited above, licensee has not renewed the Mandated Reporter training which expired on 8/14/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Licensee shall renew the Mandated Reporter (AB1207) training and submit a copy of the certificate to licensing Program before 11/09/23.
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:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: RODRIGUEZ, JACQUELIN
FACILITY NUMBER: 274416029
VISIT DATE: 10/26/2023
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Report dated 10/26/23 continues from page 1.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee was informed that if eventually a large license is granted, the maximum capacity is 14 and a helper is required to be present whenever there are more than 8 children in care and ratio (age of the children) must be observed. Licensee understands that in absence of a qualified helper, her license capacity automatically returns to capacity 8 and ratio must be observed as well. Licensee understands that the children residing in her home count as part of the capacity of the license until they turn 10 years old. The Licensee states that she transports children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA discussed the requirements of AB 633 with the Licensee. LPA also discussed "zero tolerance" related regulations with the Licensee. LPA observed that licensee has not renewed the required "mandated reporter" training which expired on 8/14/23. Licensee understands the training must be renewed every two years. LPA referred the licensee to the training website www.mandatedreporterca.com for additional information.
A review of staff records on 10/25/23 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee was reminded that all the 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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

Report dated 10/26/23 continues in page 3

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: RODRIGUEZ, JACQUELIN
FACILITY NUMBER: 274416029
VISIT DATE: 10/26/2023
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*****************Report dated 10/26/23 continues from page 2.
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/.

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.

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

During the exit interview, the LICENSEE Jacquelin Rodriguez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.


Exit interview conducted and report was reviewed with the licensee Jacquelin Rodriguez.
Three deficiencies type B were cited today.

A notice of site visit was handed to licensee and must remain posted for 30 days.
Licensee Jacquelin Rodriguez was informed that a large Family Child Care Home license would be approved pending on the following: 1) Licensee shall clear the three deficiencies cited on LIC809D and,
2) Approval from a manager of the Licensing Program.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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