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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421446
Report Date: 01/24/2020
Date Signed: 01/24/2020 02:42:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ROLLINS-RUCKER, ELIZABETHFACILITY NUMBER:
013421446
ADMINISTRATOR:ROLLINS-RUCKER, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 604-6262
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:14CENSUS: 6DATE:
01/24/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Elizabeth Rollins-RuckerTIME COMPLETED:
02:45 PM
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On 01/24/2020 Licensing Program Analysts (LPAs) Arminder Singh and Monica Mathur conducted an unannounced Plan of Correction (POC) Inspection and met with Licensee, Elizabeth.

On 01/14/2020 during an Annual/Random Inspection, facility was issued a Type A citation for Ratio & Capacity.

During today's inspection, present in the home were Licensee, her Assistant (daughter) and 6 children in care (4 infants, 2 preschool age). Faiclity is in compliance with Ratio & Capacity regulations.

Citation was cleared during today's inspection and a Letter of Clearance was issued. Licensee stated LIC9224 Statement Acknowledging Receipt of Licensing Report have been signed by parents. Report was observed to be posted.

A Notice of Site Visit was issued. This report was reviewed with the Licensee.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 622-2634
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2020
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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