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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216781
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:06:30 PM

Document Has Been Signed on 05/17/2024 04:06 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:
426216781
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
05/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Nereida Rodriguez VargasTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On 05/17/2024, Licensing Program Analyst (LPA) Martina Jimenez conducted an announced, Pre-licensing inspection for a Small Family Child Care Home (FCCH) license. LPA met with Nereida Rodriguez Vargas, applicant, the purpose of the inspection was discussed and together LPA and Applicant toured the inside and outside of the home. There were no children in care at the time of the inspection.

The applicant is requesting a small family childcare license. The home is a two story home, which consists of four (4) bedrooms, three (3) bathrooms, living room, kitchen, dining area, garage, and outdoor play area. LPA notes that the day care services will occur in the living room, dining area, kitchen, master bedroom/day-care room, bathroom, and outdoor play area. LPA notes, the three bedrooms, two (2)bathrooms and garage doors have safety knobs and safety gates at the bottom of the stairs making these areas inaccessible to children in care.

LPA observed the FCCH is fully equipped to meet the needs of children in care. LPA observed that the FCCH is clean and orderly. In addition, there is plenty of ventilation for the children in care. LPA did not observe any toxins nor hazards items accessible
Continues on LIC 809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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 6
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: 426216781
VISIT DATE: 05/17/2024
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to children in care. LPA observed that knives and medication are stored in an elevated cabinet in the kitchen & bedroom inaccessible at the time of the inspection. Cleaning compounds were observed an elevated garage cabinet that was secured at the time of the inspection making the cleaning compounds inaccessible to children in care.

The bathroom to be used for children in care was observed to be clean and free of toxins. LPA observed child size furniture and material for activities throughout the home in areas that will be accessible to children in care.

LPA and applicant toured the outdoor play area. The play area has age-appropriate toys and day-care equipment. LPA observed the exits to be secured. LPA observed there is shading to afford the children in care. In addition, Filtered water will be accessible by means of water jug with individual water cups. LPA and applicant discussed active supervision when children are in the outdoor yard.

· No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

· All adults living and working in the home shall be made of aware of the Department inspection rights authority.



There are two (2) adults living in the home, which all adults residing in the home have been fingerprint cleared.

CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 426216781
VISIT DATE: 05/17/2024
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LPA observed a regulation 2A10BC fire extinguisher in the FCCH at the time of
the inspection that was purchased on 08/11/23. Licensee is reminded to service or purchase the fire extinguisher yearly. LPA observed applicant test a combination smoke and carbon monoxide detectors in the home at 2:37 PM and were functioning at the time of the inspection. Applicant stated that there are no weapons or ammunition in the home. Applicant stated she does hold a foster family license.

Applicant completed the Family Child Care Orientation on 8/23/2023. Applicant completed the Preventative Health & Safety on 10/27/2023. Applicant is current with immunization required per SB 792. Applicant Pediatric First Aid/CPR certificate is valid until 09/02/25. Applicant’s Mandated Reporter Training certificate is valid until 08/25/2025. The applicant provided proof of control of property. Control of property was verified via receipt of lease agreement. Because the applicant, rents/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. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Applicant, 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

Continues on LIC809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 426216781
VISIT DATE: 05/17/2024
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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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) 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.

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.

LPA discussed the safe sleep regulations with applicant, and discussed the Child Care Licensing Safe Sleep web page at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource.

LPA also informed 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.
Continues on LIC809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 426216781
VISIT DATE: 05/17/2024
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On this date, 05/17/2024, 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.

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

Applicant was made aware the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.

CONTINUES ON LIC809C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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: 426216781
VISIT DATE: 05/17/2024
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The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez. A notice of site visit was given to applicant, and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the applicant, Nereida Rodriguez Vargas.

This home meets Title 22 Division 12 requirements of a Small FCCH license. Effective date of license will be noted as the present, 05/17/2024.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6