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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216804
Report Date: 11/22/2023
Date Signed: 11/22/2023 12:14:25 PM

Document Has Been Signed on 11/22/2023 12:14 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 FCC AKA CLOUD HAVEN CHILDCAREFACILITY NUMBER:
426216804
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
11/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vianna RodriguezTIME COMPLETED:
11:30 AM
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On 11/22/23, Licensing Program Analyst (LPA) Francisca Velazquez conducted an announced Pre-licensing Inspection and met with Applicant, Vianna Rodriguez. LPA informed Applicant of the nature and purpose of the inspection. The applicant informed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from 7:00 AM to 5:00 PM, Monday- Friday. The applicant also informed LPA of the intention to provide care for children from 1 year to 10 years of age. The applicant reported there are two (2) adults that live in the home and two (2) adults have received criminal record clearance.

LPA toured the interior and exterior of the residence with the Applicant. This is a single-story home that consists of three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry room, daycare room, garage, outdoor yard. The applicant reported day care services will occur in the daycare room, dining area, and one (1) bathroom will be accessible to children in care. Meanwhile three (3) bedrooms, one (1) bathroom, living room, kitchen, laundry room, garage and outdoor yard will be inaccessible to children in care. LPA observed all bedrooms have door safety knobs. LPA observed gates making the living room and kitchen inaccessible. LPA observed the laundry room and garage are locked and secured. Applicant reported the outdoor yard will be inaccessible to children for now. The applicant is planning on adding a fence to make part of the outdoor yard accessible. Applicant submitted updated outdoor facility sketch detailing the changes in the outdoor yard. LPA and Applicant clarified that once the fence is done, CCL will need to conduct an inspection to ensure the outdoor yard is safe and secure for the children in care.

LPA observed the daycare room, bathroom and dining area have plenty of spacing and ventilation for the comfort of children in care. LPA observed a fireplace in the living room that is made inaccessible by means of a gate. LPA observed sharps are stored in an elevated cabinet in the kitchen. Medication for the family is stored in a separate elevated cabinet in the kitchen and in a cabinet in the bathroom that is locked. Cleaning compounds were observed to be stored in the laundry room. LPA notes all these areas are inaccessible to children in care. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
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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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 FCC AKA CLOUD HAVEN CHILDCARE
FACILITY NUMBER: 426216804
VISIT DATE: 11/22/2023
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The bathroom of the FCCH is observed to be clean and free of toxins. LPA observed items, equipment, toys and furnishings for the children in care that are in good condition and age appropriate.

LPA observed a required fire extinguisher (2A10BC) in the home which was purchased on 11/22/23. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually. The home has a smoke and carbon monoxide detector that was tested at 10:00 AM and was operable.

LPA and applicant toured the outdoor yard. LPA observed the outdoor yard to be completely fenced and the exit gates are secured. Applicant reported the outdoor yard will be off-limits to the children in care and understands that the outdoor yard must be inspected prior to being used with the children in care. LPA did not observe any bodies of water. Applicant reported there are no guns or ammo in the FCCH.

LPA's record review revealed Applicant completed Preventative Health training on 11/13/21. Further, Applicant completed Mandated Reporter training on 11/22/23 and Pediatric CPR/First Aid (EMSA approved) on 11/19/22. Applicant completed FCCH orientation on 9/28/22. LPA reminded Applicant of obligation to maintain current training and certifications. Applicant does not have liability insurance for the license as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282).



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 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.

The applicant rents the home and provided proof of control of property. The applicant, has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 or 14 children.

CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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 FCC AKA CLOUD HAVEN CHILDCARE
FACILITY NUMBER: 426216804
VISIT DATE: 11/22/2023
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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 webpage 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.



On this date, 11/22/23, 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; 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, informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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, Vianna Rodriguez. CONT 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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 FCC AKA CLOUD HAVEN CHILDCARE
FACILITY NUMBER: 426216804
VISIT DATE: 11/22/2023
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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.

The home meets Title 22 of CCR requirements for a Small Family Child Care license effective today. Effective date of license is today 11/22/23.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
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