Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618501
Report Date: 09/29/2017
Date Signed: 09/29/2017 02:58:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:RODRIGUEZ, SHAWNAFACILITY NUMBER:
343618501
ADMINISTRATOR:RODRIGUEZ, SHAWNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 349-9791
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:14CENSUS: 12DATE:
09/29/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Shawna Rodriguez, LicenseeTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Joleen Kenney and met with Shawna Rodriguez, licensee, for an unannounced 3 year inspection. Twelve (12) children were present upon arrival.

Off-limit areas are: Garage, Master bedroom and Master bathroom. The facility was toured inside and out for a health and safety inspection. The facility appeared orderly and suitable for children. Cleaning agents are stored in latched cabinets under the sink. Knives are kept inaccessible in upper cabinet.. Fire extinguisher, smoke and carbon monoxide detectors meet State Fire Marshall standards. Licensee stated that there are no weapons at the facility. All staff present today had criminal background check clearances and/or exemptions and facility associations. LPA observed a current CPR/First Aid Certificate. Licensee had proof of immunization's to meet SB 792 for herself and her assistant. Licensee stated that no new residents moved into the home since licensure. Capacity specified on the license was met. Outdoor play area is fenced, and licensee understands that 100 % supervision is required in unfenced outside areas. LPA observed a current roster of children and documentation of fire and disaster drills. Children’s records include immunization records and signed copies of Parents Rights Notifications.

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.

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2017
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: RODRIGUEZ, SHAWNA
FACILITY NUMBER: 343618501
VISIT DATE: 09/29/2017
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LPA discussed safe sleeping practices for infants and requirement to notify the department prior to making changes to off-limit areas, or making alterations to the building. LPA provided information on AB 1207 and web site address, so that licensee can stay current in the requirements of the Department. The web site is (www.ccld.ca.gov).

NO DEFICIENCIES were observed in the areas that were evaluated at today’s inspection. An exit interview was conducted and a Notice of Site Visit was posted.

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2017
LIC809 (FAS) - (06/04)
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