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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573617267
Report Date: 09/09/2026
Date Signed: 09/09/2026 12:44:41 PM

Document Has Been Signed on 09/09/2026 12:44 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:INIGUEZ, ROSAFACILITY NUMBER:
573617267
ADMINISTRATOR/
DIRECTOR:		INIGUEZ, ROASFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 668-8885
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 0DATE:
09/09/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Rosa IniguezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Rosa Iniguez is a Spanish speaking Licensee. Licensing Program Analysts (LPAs) Corina Beckby and Elizabeth Santiago spoke with Licensee in Spanish and translated the conversation to English below. LPAs conducted an unannounced annual inspection and met with Licensee, Rosa Iniguez. LPAs were granted entrance into daycare facility by licensee. LIC 126 (SP), Entrance Checklist for Family Child Care Homes, was provided and reviewed with Licensee. Present in the facility was Licensee and her two adult children. Licensee was not caring for children at the time of inspection. Facility hours of operation are Monday – Friday from 6:00 am – 6:000 pm. LPA verified that annual fees are current.

Licensee was reminded that all adults 18 and over living or working in the home, 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. Licensee was reminded that proof TB immunization's are required for all adults living in the home.

A health and safety inspection was conducted in all areas accessible to children. Upon entry, LPAs observed the required postings and verified phones are working. Off-limit rooms are: all bedrooms, master bathroom, laundry room, garage, left and side yards and front yard. Off-limits areas will remain inaccessible to children by closed doors, gates, and/or supervision.

Continued on LIC 809-C...

Bettina Engelman
Corina Beckby
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/09/2026 12:44 PM - It Cannot Be Edited


Created By: Corina Beckby On 09/09/2026 at 11:55 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: INIGUEZ, ROSA
FACILITY NUMBER: 573617267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that the fire drill was not available, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2026
Plan of Correction
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Licensee will email a picture of fire drill log due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: INIGUEZ, ROSA
FACILITY NUMBER: 573617267
VISIT DATE: 09/09/2026
NARRATIVE
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Toys appear to be safe and in working order. Home is clean and properly ventilated. The fireplace has tempered glass. Fireplace is appropriately barricaded to prevent access by children. Functioning smoke and carbon monoxide detectors were observed, tested and meet Title 22 regulations. LPAs observed a 3A40BC fire extinguisher. Sharp utensils are inaccessible to children. LPAs observed the restroom and verified hazardous and toxic items were inaccessible to children in care. Licensee understands she must ensure the safety locks are not broken. The backyard is fenced. There are no bodies of water on the premises. Licensee states there are no weapons in the home.



LPAs observed a current roster. LPAs reviewed 1 child’s files. Preventative health and current pediatric CPR and first aid training were verified for Licensee. CPR expires 02/08/2027. Mandated Reporter Training certificate expires: 02/25/2027Licensee understands the training must be completed once every two years, and training is accessible at https://mandatedreportertraining.com/california/

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.



LPAs discussed the safe sleep regulations with licensee 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. LPAs also informed licensee of the importance of checking for and removing any 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. LPAs reminded Licensee that sleep logs must be maintained for all children under the age of 2 years.

Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: INIGUEZ, ROSA
FACILITY NUMBER: 573617267
VISIT DATE: 09/09/2026
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LPAs provided the main office number for the Sacramento South Regional Child Care office (916) 263-5744 for licensees to call and report injuries or unusual incidents within 24 hours of the incident and reviewed the form (LIC 624B) to follow up in writing within 7 days of the incident. LPAs encouraged Licensee to visit the department website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes. LPAs reminded Licensee to advise the department of any and all facility closures (vacations, holidays, and illness). LPA explained to Licensee that absences shall not exceed 20% of the facility’s monthly working hours.


LPAs discussed and provided Never Shake A Baby Poster (PUB 273-A2) and Pamphlet PUB 271 (2/17). Licensee was reminded to notify LPA of any changes to her hours of operation. Licensee understands inspections will be conducted whether children are enrolled or not.

Licensee was informed of the MyChildCarePlan.org website; 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process .

LPAs informed Licensee, Rosa Iniguez, that this report dated 09/09/2026, documents a Type B citation that is a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for the deficiency.

An Exit interview was conducted, and the report was reviewed with Licensee, Rosa Iniguez. LPAs posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of five years for public review upon request. The Licensee's signature on this form acknowledges receipt of this form.

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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