Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618696
Report Date: 10/23/2019
Date Signed: 10/23/2019 02:25:53 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, TINAFACILITY NUMBER:
343618696
ADMINISTRATOR:RODRIGUEZ, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-6040
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 6DATE:
10/23/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Tina RodriquezTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jeevun Birk-Miller conducted an unannounced annual random inspection and met with licensee, Tina Rodriquez. All individuals subject to criminal background review have obtained a criminal record clearance. During the inspection the licensee's daughter, assistant, and six children were present.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include the entire upstairs, laundry room, and garage. LPA observed the required postings, a working phone, 3-A-40-BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no bodies of water on the premise. Toxic and hazardous items are inaccessible to children. The fireplace in the home is appropriately barricaded to prevent access by children and outdoor play space is fenced.

Five children’s files were reviewed. Emergency information were on file. During review of the children's files at 1:12 PM LPA observed that four out the five (C1-C4) files were missing the Notification of Parent's Rights form and Parent Notification of Additional Children in Care. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in person EMSA CPR and First Aid certification was verified and expires 08/2021 and AB 1207 Mandated Reporter Training which expires 03/2020.

This provider is currently not providing IMS services to children in care. 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.
Report continues on 809-C.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
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 3
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, TINA
FACILITY NUMBER: 343618696
VISIT DATE: 10/23/2019
NARRATIVE
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LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov. LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures. LPA provided the website for the mandated reporter training. www.mandatedreporterca.com LPA also discussed the new Immunization Card and changes to the Mandated Reporter Training.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form. In the areas that were evaluated, the following Type-B deficiencies were cited under California Code of Regulation Title 22. Refer to the 809-D page of this report.

SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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, TINA
FACILITY NUMBER: 343618696
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2019
Section Cited

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Child's Records. 102421(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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This requirement was not met as evidenced by: Based on record review the licensee failed to ensure that chilren's files for four children were complete. This poses a potential health and safety risk to children in care.
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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.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Jeevun BirkTELEPHONE: (916) 917-6078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2019
LIC809 (FAS) - (06/04)
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