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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215624
Report Date: 08/26/2021
Date Signed: 08/26/2021 05:36:48 PM

Document Has Been Signed on 08/26/2021 05:36 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
426215624
ADMINISTRATOR:CONCEPCION RODRIGUEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 735-9060
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Concepcion Rodriguez and Lupita RodriguezTIME COMPLETED:
05:40 PM
NARRATIVE
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On August 26, 2021, at 3:00 PM, Licensing Program Analyst (LPA) S. Mendoza-Ceja conducted an unannounced Required 1 year inspection. LPA met with Licensee Concepcion Rodriguez and her adult daughter Lupita "Luz" Rodriguez. Prior to entry to the home, LPA conducted a risk assessment for COVID-19. Licensee escorted LPA through the home. The Licensee Concepcion Rodriguez stated the child care is conducted in the primarily in the day care room (living room) and dinning area, but are primarily play outside in the fenced front yard. The entire home was inspected, including the off limit areas. The home was observed to be clean and orderly. The primary day care room was observed to be appropriately furnished with toys. LPA observed the COVID-19 posters posted for review. Licensee stated she conducts daily temperature checks and documents this when the children arrive. The off-limit areas of the home are the bedrooms which one door has plastic door cover, another is a key lock, and gate making the kitchen inaccessible to day care children.

The required 2A10 BC fire extinguisher was purchased on 06/01/2020. Licensee is reminded the 2 A10 BC fire extinguisher needs to be serviced or replaced yearly. There is carbon monoxide detector and smoke detector which were tested and operational. LPA discussed firearms and ammunition, Licensee stated there are no guns and ammunition in the home or bodies of water on the premises. LPA did not observe any bodies of water on the premises. LPA also reviewed emergency contact information for children enrolled in the day care. Review of records and interview with Licensee revealed she has completed the Individual Infant Sleeping Plan (LIC9227) for three of the infants in care. Licensee stated they supervise the infants during nap time in the day care room/living room. However, has not documented the 15 minute-check for the infants in care. LPA reviewed and provided handouts for Regulation 102425 and discussed infant care with Licensee and her adult daughter including Individual Infant Sleeping Plan (LIC9227) and Sleeping Chart.

During the inspection, LPA observed child #1 sleeping in a bassinette which is not approved napping equipment in licensed child care facilities.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215624
VISIT DATE: 08/26/2021
NARRATIVE
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Licensee Concepcion Rodriguez has current AB1207 Child Abuse Mandated Reporter Training is certification is current (expires 07/29/2023 and assistant Lupita Rodriguez did not have verification available for review. Licensee Concepcion Rodriguez and her adult daughter Lupita Rodriguez have current Child, Infant and Adult CPR and First Aid (expires 01/17/2022).

Verification of MMR, Tdap, and Flu were available for review licensee and her assistant.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.


Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, refer to LIC809Ds. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee



Failure to post the "Notice of Site Visit" for 30 days may result in a $100.00 civil penalty.

Report was translated in Spanish by Lupita "Luz" Rodriguez.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/26/2021 05:36 PM - It Cannot Be Edited


Created By: Sylvia Mendoza-Ceja On 08/26/2021 at 04:19 PM
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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2021
Section Cited
CCR
102425(a)(1)

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102425 INFANT SAFE SLEEP (a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (1) All cribs or play yards shall meet the United States Consumer Product Safety Commission safety standards.

This requirement was not met by:
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During the inspection the Licensee stated she would discard the bassinette.
LPA observed the bassinette in the trash.
Deficiency Cleared.
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LPA observation and interview, child #1 sleeping in a bassinette which is not approved napping equipment in licensed child care facilities.
This poses a potential risk to the health and safety of children in care.
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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:Ana Tolentino
LICENSING EVALUATOR NAME:Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2021 05:36 PM - It Cannot Be Edited


Created By: Sylvia Mendoza-Ceja On 08/26/2021 at 04:27 PM
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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 426215624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
102425(j)(D)

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102425 (j) (D) INFANT SAFE SLEEP Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date. b. Infant’s name. c. Time of each 15-minute check.

This regulation was not met by:
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Please correct Immediately.
Licensee shall submit a written plan to Licensing for review by 08/30/2021 and copies of the Check List for review.
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LPA observation, review of records, and interview revealed the 15- minute checks were not documented for child #1, child #2, and child #3. This poses a potential risk for childinc are in care.
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Type B
08/30/2021
Section Cited
HSC1596.622(a)(1)

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1596.622(a)(1) Health and Safety - Child Abuse Mandated Reporter Training: On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider...employee of a licensed child day care facility shall complete the mandated reporter training every 2 years following the date on which he or she completed.
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Licensee shall submit a written plan to Licensing for review by 08/30/2021.
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This requirement was not met as evidenced by the record review and interview which revealed the Child Abuse Mandated Reporter Training was not completed for assistant Lupita Rodriguez. This poses a potential health and safety risk to children in care.

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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:Ana Tolentino
LICENSING EVALUATOR NAME:Sylvia Mendoza-Ceja
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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