304314341-5-10-2024-06-CC-GLUO-D55R9T-20240510125004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314341
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:50:24 PM

Document Has Been Signed on 05/10/2024 12:50 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	RODRIGUEZ, MARIA		FACILITY NUMBER:	304314341
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	05/10/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Applicant Maria Rodriguez		TIME VISIT/ INSPECTION COMPLETED:	12:50 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	(Page 1) On 05/10/2024, Licensing Program Analysts (LPAs) Giselle Lucero and Alma Castro conducted an announced, in-person Pre-Licensing inspection for a new Small Family Child Care home. The LPAs met with applicant Maria Rodriguez, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates 3 adults live in the home. The adult residents received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there are no minors living in the home. The applicant stated that they are not registered with any Resource Foster Care agency and that they do not hold a Resource foster parent license. The applicant was reminded to notify the licensing office of any changes. The applicant is requesting a Small Family Childcare Home license. Per the applicant, operation hours will be Monday- Friday, 6:00 AM- 6:00 PM. Care and supervision will be provided to children ages 0-17 years. For the purposes of licensing, an infant is defined as any child 0 to 24 months of age. All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a house with 2 bedrooms, 2 bathrooms, a living room, a dining room, kitchen, garage, front yard, and back patio. There is a fireplace located in the living room barricaded by TV stand inaccessible to children. Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated the 2 bedrooms, living room, a bathroom in a bedroom, garage, and the front yard as off limits. (Continue Page 2)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

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(Page 2)
The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

Areas Designated for Day Care Activities: The applicant has designated the dining room, kitchen and one bathroom located in the hallway as areas for day-care use. LPAs observed there was a baby gate located by the living room way to prevent children from entering the off-limit living room and child proof doorknobs to prevent children from entering the off-limit bedrooms.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).

Smoke and carbon monoxide detectors were tested and are operable. The fire Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 3A-10BC fire extinguisher indicates fully charged and is located on a wall in the kitchen. Extinguisher type 3A-10BC must be serviced annually or as often as necessary.

OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard patio. The backyard patio appropriately fenced. LPA observed age-appropriate play equipment to be free from hazards. There are no bodies of water on the premises.

(Continue Page 3)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 2 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

NARRATIVE

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(Page 3)
The applicant stated the parents have the option to bring meals from home or meals will be provided by applicant. The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Per the applicant, children will nap in the dining room. Children will nap on cots and infants in cribs/play yards. The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. The applicant stated that parents will provide linens and blankets for napping.

The applicant stated that parents will provide diapers, lotion, wipes, and formula for the infants. Per the applicant, a changing table that is attached to a play pen will be used to change diapers. LPA observed the changing table inside the day-care room. LPA advised the applicant to always supervise at all times infants when changing their diapers.

A records review indicates the applicant completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicant has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 06/10/2025.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

Only during Covid-19 outbreak, the applicant will receive children at the front door. Per the applicant, upon arrival children’s temperature will be taken, their hands will be sanitized, and the children will be taken to the designated day care area by the applicant. COVID-19 guidelines and precautions were discussed with the applicant.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

(Continue Page 4)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

NARRATIVE

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(Page 4)
Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1. Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.

No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, which includes but is not limited to the right to enter the home. When children are being cared for, interview children and adults, and review documentation.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

(Continue Page 5)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 4 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

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(Page 5)
H&S 1597.622: 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. The applicant has submitted proof of immunizations.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicant has completed the required mandated reporter training. Recertification is required every two years.

The LPA advised the applicant(s) on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.
Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

(Continue Page 6)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 5 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

NARRATIVE

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(Page 6)
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.

STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record
Exemption Transfer Request (LCI 9188).

INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative.

Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

(Continue Page 7)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 6 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

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(Page 7)
OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Maria Rodriguez 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, 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.

Landlord Consent

APPLICANT LEASES THE HOME AND DOES NOT HAVE LANDLORD CONSENT:

Because the applicant, leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. Landlord consent was not obtained, LPA advised applicant she can only care up to 6 children until landlord consent is obtained. LPA obtained statement from applicant stating she will only care for up to 6 children until landlord consent is obtained. The applicant was reminded to notify the licensing office of any changes.

Incidental Medical Services Plan (IMS)

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (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 Incidental Medical Services (IMS) - Family Child Care Homes

(Continue Page 8)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 7 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

NARRATIVE

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(Page 8)
Review of records to be maintained:

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. Entrance Checklist was provided to the applicant.

Safe Sleep

LPA discussed the safe sleep regulations with the applicant 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. LPAs also informed the 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.

Megan’s Law

On this date, 05/10/2024, 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 addresses. 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.

MyChildCarePlan.org

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

(Continue Page 9)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: RODRIGUEZ, MARIA	FACILITY NUMBER: 304314341
	VISIT DATE: 05/10/2024

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(Page 9)
Exit Interview
Exit interview conducted and report was reviewed with the applicant Maria Rodriguez.

Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:

Subscribe to CCLD important information
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 platforms.

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.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The Small Family Child Care Home was in compliance with Title 22 Regulations at the time of inspection. In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met.

Appeal rights were provided. Exit interview conducted and report was reviewed with Maria Rodriguez.

End of Report.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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