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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700230
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:24:17 PM

Document Has Been Signed on 08/22/2023 12:24 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
367700230
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:MARIA RODRIGUEZTIME COMPLETED:
12:50 PM
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On August 22, 2023, Licensing Program Analyst (LPA) Babatunde Ibitoye met with Licensee Maria Rodriguez to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self reported unusual incident report (UIR) submitted to the Department on August 7, 2023.

Description of incident: C#1 was hurt by his sibling C#2, C#2 was mid Picking C#1 when he drop,C#2 did put his hands out but C#1 still hit the ground with his nose,which followed with C#1 nose bleed. Before injury Licensee redirected C#2 to not pick C#1 up and not play rough with C#1.

Present during the time of this inspection is the Licensee, Adult daughter and 4 day-care children, The copy of the facility roster was collected.

Further investigation is needed, An exit interview was conducted, and a copy of this report was read and provided to the Licensee Maria Rodriguez along with a Notice of the Site Visit.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Babatunde Ibitoye
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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