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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845929
Report Date: 03/16/2023
Date Signed: 03/16/2023 11:23:28 AM

Document Has Been Signed on 03/16/2023 11:23 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:RODRIGO FAMILY CHILD CAREFACILITY NUMBER:
334845929
ADMINISTRATOR:RODRIGO,KIVINIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 854-4232
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
03/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Kivini Rodrigo, LicenseeTIME COMPLETED:
11:30 AM
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On March 16, 2023, Licensing Program Analyst (LPA) Kay Turner arrived at the facility on a case management visit to follow-up on an unusual incident report submitted by the facility on March 15, 2023. At the time of visit, LPA toured the facility (specifically were the reported incident took place), took census, and met with Licensee, Kivini Rodrigo, to discuss the reported incident. The subject child involved in the incident was not interviewed by the LPA, as the child was not in attendance at the facility.

Based on the information obtained during the visit, as well as an inspection of the location where the alleged incident occurred (photographs of file), no citations were issued pertaining to the reported incident.

An exit interview was held with Licensee, Kivini Rodrigo. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Karrene Turner
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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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