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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618696
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:25:29 AM


Document Has Been Signed on 03/05/2024 11:25 AM - 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:
03/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fatima BattisteTIME COMPLETED:
11:45 AM
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On 03/05/2024, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the facility for the purpose of a Plan of Correction inspection. LPA arrived at the family childcare home (FCCH) and was met by Assistant Fatima Battiste Ortiz (A1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. LPA observed 2 infants and 6 preschool aged children being supervised by A1. Also present in the FCCH was an adult resident. LPA determined through accessing Guardian that all required adults were background cleared and associated to the license. Licensee Rodriguez gave her verbal consent over the telephone for A1 to sign the report(s). LPA confirmed that A1 has current First Aid and CPR training.

During an Annual Random Inspection conducted on 01/29/2024, Licensee Rodriguez was issued a deficiency for not having children's files with required forms and immunizations. The plan of correction due date was agreed upon for 02/29/2024. During today's inspection on 03/05/2024, LPA reviewed the files for the currently enrolled children and observed completed files with immunizations and Safe Sleep related forms. LPA cleared the deficiency and provided A1 with a letter of clearance.

An exit interview was conducted, and the report was reviewed with Assistant Battiste Ortiz. LPA provided A1 with Licensee Appeal Rights. 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: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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