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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618696
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:16:56 PM


Document Has Been Signed on 01/29/2024 04:16 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:RODRIGUEZ, TINAFACILITY NUMBER:
343618696
ADMINISTRATOR:RODRIGUEZ, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 271-6040
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:14CENSUS: 8DATE:
01/29/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tina RodriguezTIME COMPLETED:
04:30 PM
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On 01/29/2024, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Tina Rodriguez (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA observed 2 infants, 5 preschool aged children, and 2 school aged children being supervised by L1 and 1 Aide. Also present in the FCCH was an adult resident. LPA accessed Guardian to determine that all required adults were background cleared and associated to the license. L1 stated that there are no new residents in the home since licensure and confirmed that there are no Registered Sex Offenders living in the facility.

LPA toured the areas of the FCCH that are accessible to children in care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include the laundry room, entire upstairs, garage, pool, and shed (in the backyard). L1 acknowledged that children may never enter these OFF-limits areas. L1 reports her hours of operation to be 7 days per week for 23 hours per day.

LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA was unable to review children’s files. LPA reviewed the adult’s files and immunizations. LPA reviewed the Facility’s Roster and observed the Fire Drill log to ensure that drills are conducted at least once every 6 months. A functioning smoke detector and carbon monoxide detector were observed in the downstairs hallway and tested. LPA observed cleaners stored on top of the refrigerator in the kitchen. L1 stated that cleaners and detergents are stored in the Off-limits laundry room. LPA observed children's medications stored in the kitchen refrigerator which were inaccessible to children in care. LPA observed additional medications which were stored in kitchen cabinets which were inaccessible to children in care.

Continued on 809-C

SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RODRIGUEZ, TINA
FACILITY NUMBER: 343618696
VISIT DATE: 01/29/2024
NARRATIVE
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LPA observed knives stored on top of the refrigerator in the kitchen. L1 stated that the fireplace in the living room is not used during operational hours. LPA observed a baby-gate barricading the stairway to make the stairs inaccessible to children. LPA observed a 2A10BC fire extinguisher by the main entrance which appeared to be in the green zone. Toys appeared to be safe and in good supply. LPA observed an in-ground pool that was surrounded by a fence that was measured at 5 feet high with a self-latching and self-closing gate. LPA walked the perimeter of the backyard and ensured the stability of the surrounding fence. L1 stated that there are no firearms in the FCCH. L1 stated that she does not own any pets.

LPA discussed Mandated Reporter Training with the L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. Current Pediatric CPR and First Aid training was also verified by LPA and will expire on 01/27/2026.

LPA discussed the Safe Sleep Regulations with L1 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 L1 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 that s/he register all infant devices with the CPSC to be notified of any recalls on purchased equipment.

Incidental Medical Services (IMS) policy was discussed with L1. 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/.

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 through this communication platform. To receive important licensed related information, Continued on LIC 809-C

SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
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: RODRIGUEZ, TINA
FACILITY NUMBER: 343618696
VISIT DATE: 01/29/2024
NARRATIVE
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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. L1 was informed of the MyChildCarePlan.org; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

L1 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.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. L1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. L1 understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years.



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.

Title 22 deficiencies were cited on 01/29/2024 on subsequent 809-D pages. L1 acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 9099-D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. Continued on LIC 809-C
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
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: RODRIGUEZ, TINA
FACILITY NUMBER: 343618696
VISIT DATE: 01/29/2024
NARRATIVE
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 An exit interview was conducted, and the report was reviewed with Licensee Tina Rodriguez. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/29/2024 04:16 PM - It Cannot Be Edited

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: RODRIGUEZ, TINA
FACILITY NUMBER: 343618696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above when an infant was placed in a play yard with blankets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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Licensee Rodriguez will review the Safe Sleep documents which LPA provided and review the safe sleep website (website link on 809 Report). Licensee will sign a statment declaring that she reviewed both the Safe Sleep documents and website and email the signed statement to LPA by 5 PM on 01/30/2024.
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.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 01/29/2024 04:16 PM - It Cannot Be Edited

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: RODRIGUEZ, TINA
FACILITY NUMBER: 343618696

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above when LPA was not able to review children's files with all required documents including th emergency information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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LPA will conduct a file review during an unnounced field visit after 02/29/2024.
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.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6