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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376628204
Report Date: 01/26/2022
Date Signed: 01/26/2022 12:57:19 PM

Document Has Been Signed on 01/26/2022 12:57 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:RODRIGUEZ, MAYRA & WILFREDO FAMILY CHILD CAREFACILITY NUMBER:
376628204
ADMINISTRATOR:MAYRA & WILFREDOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 305-5400
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
01/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mayra & Wilfredo RodriguezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 01/26/2022 Licensing Prigram Analyst (LPA) Dana Stevens conducted an unannounced Case management visit for the purpose of citing deficiency discovered during complaint investigation. LPA met with Mayra and Wilfredo Rodriguez and informed them of the purpose of the visit.

During complaint investigation Licensee informed LPA that law enforcement was called to the house on an occasion when Child 1(C1) was having behavioral issues. Review of facility records and documentation from outside agencies this incident occurred during daycare hours of operation but was not reported to Licensing Department as an unusual incident.

The California Code of Regulations per Title 22, Section 102416.2(b)(3)(C) is being cited. Please refer to LIC 809-D for type-B deficiency cited.

Licensee will correct the deficiency by submitting an Unusual Incident Report to LPA within 7 days.

A copy of this report and appeal rights were provided to Licensee via email. Licensee was advised that acknowledgement of receipt of the report and appeal rights are to be received within twenty-four hours.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Dana Stevens
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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 2
Document Has Been Signed on 01/26/2022 12:57 PM - It Cannot Be Edited


Created By: Dana Stevens On 01/26/2022 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: RODRIGUEZ, MAYRA & WILFREDO FAMILY CHILD CARE
FACILITY NUMBER: 376628204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2022
Section Cited
CCR
102416.2(b)(3)(c)

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102416.2(b)(3)(C)Reporting Requirements..."A report shall be made to the Department... Any unusual incident... that threatens the physical or emotional health or safety of any child."
This requirement was not met as evidenced by:
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Licensee will submit the LIC 624b documenting the Unusual Incident within 7 days.
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Based on record reveiw and interview Licensee did not meet the requirement of reporting an unusual incident within 24 hours to the Licensing Department which 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:Cynthia Gray
LICENSING EVALUATOR NAME:Dana Stevens
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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