Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203804438
Report Date: 11/02/2018
Date Signed: 11/13/2018 09:49:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:RODRIGUEZ FAMILY CHILD CAREFACILITY NUMBER:
203804438
ADMINISTRATOR:RODRIGUEZ, GABRIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 661-8829
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY:14CENSUS: 6DATE:
11/02/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Gabriela RodriguezTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Required 3 Year inspection was conducted by Licensing Program Analyst, Patricia Musso today 11/2/18. Present at the time of LPA's arrival with licensee was licensee's husband and her friend Yolanda Hernandez. Licensee said Yolanda came over to talk about assisting licensee with the day care children. At the time of LPA's arrival Yolanda was sitting on one of the couches supervising one of the infants.
Background clearances were discussed and licensee signed LIS531 indicating adults residing in the home and/or working in the facility have a criminal record clearance and/or have an exemption.
A tour of the facility was conducted and the following was observed and/or discussed:
· Verified licensees’, Pediatric CPR and First Aid card with the expiration date 5/2019..
· This is a one story home.
· Licensee said she has a current roster of children in care but was unable to find during
this inspection.
· Facility has a fire extinguisher, working smoke alarm, carbon monoxide alarm, and first
aid kit.
· Cleaning products, knifes, and medications are stored out of the reach of children.
· Licensee states there are no poisons in the home or premises. She understands if
present they are to be stored in locked area and inaccessible to children.
· Licensee states there are no weapons in or on the premises.
· There is a fireplace in the living but is never used.
· Verified facility has a landline and cell and confirmed phone numbers.
· The home is clean and orderly and has central heating and air conditioning for comfort.
· Care and supervision is provided in the kitchen, dining, living and bath rooms. Facility
has child size furniture, toys, and games.
· Fire drills are conducted once every six months and are documented with the date and
time but licensee was unable to find the log during this inspection.
· Off-limits rooms are made inaccessible by use of baby gates.
Hours of operation are Monday - Sunday, 4:30 AM to 6:30 PM Licensee states overnight care less than 24 hours is not provided.
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Patricia MussoTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2018
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 203804438
VISIT DATE: 11/02/2018
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· The licensee understands that children must be supervised at all times.
· There is one small dog that is outside when the children are inside and then it is put in a
area that is inaccessible to the children when they go outside.
· Licensee understands it is her responsibility to keep the children safe from the pets at all
times.
· There are no bodies of water in or on the premises.
· Required items were posted on the wall where parents may easily view.
· Backyard contains different type of toys for the children. The back yard if off limits this
week and next while some work is being done in the back yard.
· Various children’s files were reviewed for emergency information.
Licensee said she had her immunizations/vaccines per SB792, but was unable to find the proof LPA provided licensee with a copy of the SB792.
Incidental Medical Services (IMS) policy were discussed. Licensee said she does not have any children with the need of medical services. 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. During this inspection
LPA provided licensee the IMS - FCCH Requirement guidelines
Licensee is advised forms and updated information may be obtained on the CCLD website (www.ccld.ca.gov). She is also advised it is her responsibility to stay current with the regulations.
Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are cited on LIC809D (see next page LIC809D). Licensee was reminded to follow the AB633. Licensee is advised to make this licensing report accessible to the public and to provide copies of this licensing report and 809D with Type A citation to parents/legal guardians of children in care and to parents/legal guardians of children newly enrolled at the facility during the next 12 months. Licensee is to keep verification of receipt (LIC9224) in each child's file at the facility.

In exit interview licensee was reminded that licensed capacity is not only based on maximum number of children in care, but by ages as well. Licensee was advised of appeals rights and provided with a copy of Appeals Rights. LPA observed licensee post the Notice of Site Visit and report with Type A deficiencies prior to leaving the facility. Licensee was also advised this report must remain posted for 30 days where parents may easily view and filed in facility file for public review for 3 years. Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Patricia MussoTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2018
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 203804438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2018
Section Cited
HSC
1597.622
1
2
3
4
5
6
7
H&S1597.622 Employees or volunteers at family day care home; immunization requirements; records; exemptions: a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. This requirement is not met by evidence of files reviewed during today's inspection where licensee
1
2
3
4
5
6
7
Licensee said she will find her proof of the required immunizations /vaccines of the pertussis, measles and influenza.
8
9
10
11
12
13
14
family day care home if he or she has not been immunized against influenza, pertussis, and measles. This requirement is not met by evidence of files reviewed during today's inspection where licensee informed LPA that she could not find the proof of the measles immunization. This poses a possible risk to the health, safety, or Personal rights of children in care.
8
9
10
11
12
13
14
Licensee is to call LPA by 11/16/18 to inform LPA if she needs to be immunized again or if she found the proof.
Proof needs to be submitted to CCL by Nov 30, 2018
Type B
11/02/2018
Section Cited
CCR
102417(g)(8)
1
2
3
4
5
6
7
102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children. This requirement is not met by evidence of files reviewed during today's inspection where licensee informed LPA that she could not find the Roster This poses a possible risk to the health, safety, or Personal rights of children in care.
1
2
3
4
5
6
7
Licensee will provide a copy of her current Roster to LPA by 11/30/18.
Type B
11/30/2018
Section Cited
CCR
102
1
2
3
4
5
6
7
102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement is not met by evidence of files reviewed during today's inspection where licensee informed LPA that she could not find her log. This pose a possible risk to the health, safety, or Personal rights of children in care.
1
2
3
4
5
6
7
Licensee will provide a copy of her fire drill log to LPA by 11/30/18.
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: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Patricia MussoTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2018
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: RODRIGUEZ FAMILY CHILD CARE
FACILITY NUMBER: 203804438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2018
Section Cited
CCR
102370(d)(1)
1
2
3
4
5
6
7
102370(d)(1) Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a
1
2
3
4
5
6
7
Yolanda left this facility once LPA informed licensee of this deficiency. During this visit LPA called CCL office and confirmed that Yolanda's fingerprints are now inactive.
Licensee understands that before she hires Yolanda to assist her with the children, Yolanda needs
8
9
10
11
12
13
14
California clearance or a criminal record exemption as required by the Department. At the time of LPA's arrival, licensee's friend Yolanda Hernandez. was sitting on one of the couches supervising an infants.
8
9
10
11
12
13
14
to be reprinted, cleared and associated to this facility in addition to other requirements.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Patricia MussoTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2018
LIC809 (FAS) - (06/04)
Page: 4 of 4