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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624561
Report Date: 12/06/2022
Date Signed: 12/06/2022 09:32:41 AM

Document Has Been Signed on 12/06/2022 09:32 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:RODRIQUES, ANITAFACILITY NUMBER:
343624561
ADMINISTRATOR:RODRIQUES, ANITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 418-4600
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
12/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rodrigues, AnitaTIME COMPLETED:
09:45 AM
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On Tuesday, December 6 2022, Licensing Program Analysts (LPAs) Alize Tillery and Matt Gallo met with Applicant Anita Rodrigues for the purpose of conducting an announced change of location pre-licensing inspection. During today's inspection, applicant was present in the home. Applicant and adult assistants have criminal record clearances on file. Applicant plans to operate Monday – Friday from 7:30 AM to 5:00 PM.

A health and safety inspection was conducted inside and outside the home. The home includes 3 bedrooms, 2.5 bathrooms, playroom, garage, front porch and a fenced back yard. Off-limit areas will include: the entire second floor, garage and front porch. Applicant understands that children may never enter these off-limit areas.



There is no fireplace in the home. Toxic and hazardous items are inaccessible to children and out of children’s reach. Sharp knives are stored in the kitchen, out of children’s reach. Children’s medications will be stored in a lock box, out of children’s reach. A functioning smoke detector, carbon monoxide detector and a full 2A10BC fire extinguisher was observed in the home. LPA observed all required licensing postings. COVID19 guidelines were discussed.

Report continues on LIC809-C.

LPA discussed Unusual Incident Report requirements with applicant. Applicant completed the required Preventative Health and Safety course and Applicant has a current EMSA certified CPR and First Aid card which expires 6/11/2024. Applicant also has a current Mandated Reporter Training certificate that expires on 11/18/2023. Applicant stated there are no weapons in the home and there are no bodies of water on the premises. Applicant understands that prior to making alterations or additions to the home or grounds, he/she shall notify the Department of the proposed changes.

Report continues...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: RODRIQUES, ANITA
FACILITY NUMBER: 343624561
VISIT DATE: 12/06/2022
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Applicant was encouraged to visit the Department’s website at www.cdss.ca.gov for more information regarding child care updates, forms, regulations and legislation. This report and a Notice of Site Visit was reviewed and provided to Licensee. Licensee acknowledges the Notice of Site Visit must be posted for 30 days.

As of today, December 6, 2022, facility is approved for a Large Family Child Care Home license for a maximum capacity (when there is an assistant present): 12 – no more than 4 infants. Capacity of 14 – no more that 3 infants, 1 child in kindergarten or elementary school and 1 child at least age 6.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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