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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014215
Report Date: 07/22/2022
Date Signed: 08/04/2022 04:24:47 PM


Document Has Been Signed on 08/04/2022 04:24 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/26/2022 07:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

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**This is an Amended report completed by LPA Martinez-Garza on 07/26/2022 to include the Type A requirements, upon receiving a Type A deficiency. Please see the last LIC809C.**

On July 22, 2022, Licensing Program Analysts (LPAs) Monique Ayala and Veronica MartinezGarza conducted an unannounced Required 1 Year inspection at the above facility. Upon arrival LPAs were greeted by licensee, Graciela Rubalcaba. LPAs observed 12 children in care with licensee and assistant. LPAs observed 16 children files, 4 that were infants and did not have the Infant Sleeping Plan (LIC9227) all other files had the required licensing documents. The licensee is operating within proper capacity and ratios. LPAs observed licensee to be present at the home; hours of operation are Monday through Friday, 6:00 AM to 6:00 PM.

This is a single story house with 3 bedrooms, 1 bathroom, dinning room, kitchen and laundry area with chemicals and cleaning compounds inaccessible to children in care.

The day care takes place in living room, dinning room, kitchen, 1 bedroom, and hallway bathroom. The home is clean, orderly, comfortable and well ventilated.

Licensee's poisons, detergent, cleaning compounds, medications and other items which could pose a danger to child are stored where they are inaccessible to children. LPAs observed working smoke detector and Carbon Monoxide, fully charged fire extinguisher and working telephone.

During the inspection LPAs observed infant 1 and infant 2 sleeping in room 1 where the matresses did not have fitted sheets and in the crib where infant 1 was sleeping, there were bumpers placed around the crib. Licensee removed all loose covers/sheets and bumper right away and stated she was unaware of the Safe Sleep Regulation. LPAs observed 5 school age children in the dinning room unsupervised with a knife on the counter top, accessible to children in care. LPAs provided consultation with the licensee regarding supervision and infant safe sleep.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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 23


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/22/2022
NARRATIVE
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There are several age appropriate toys and a first aid kit on the premises. Per the licensee, there are no firearms on the premises. The licensee has current CPR and first aid that expires 05/04/2023.

The licensee has not completed the online mandated reporter training at www.mandatedreporterca.com. LPAs did not observe the licensee to have an updated mandated reporter training.


All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years

The licensee has the required immunization's.

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

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/22/2022
NARRATIVE
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The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507

Per the licensee, fire and disaster drills are conducted every 6 months; licensee has not conducted a fire drill since 2018.

Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee:


Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee was reminded that supervision is always required to children in care.

Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.


-- Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/22/2022
NARRATIVE
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The on Duty Worker is available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM.

A copy of Safe Sleep Regulation and Supervision was provided to Licensee.

LPAs provided consultation during inspection.

Based on the LPAs’ observations and records reviews, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code od Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

Upon receipt of a Type A deficiency, a copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent.

An exit Interview was conducted, a copy of this Report and a Notice of Site visit was provided to the licensee.

SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 23
Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on observation, the licensee did not comply with the section cited above LPAs observed kitchen knife on top of the counter accessible to children in care which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee removed knife and made it inaccessible to children in care.
Type A
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, LPAs observed loose sheets in crib and playpens where infants were sleeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee removed loose sheets

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 5 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

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
1
2
3
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Based on observation the licensee did not comply with the section cited above LPAs observed loose sheets in crib and playpens where infants were sleeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee removed loose sheets
Type A
Section Cited
CCR
102425(b)(2)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (2) Bumper pads shall not be used.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPAs observed bumper pads in crib where infant was sleeping which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee removed bumper pads

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 6 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above LPAs observed children in dinning are unsupervised which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee will ensure she will supervise children at all times
Type A
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe infants sleep log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee will start implementing documentation of infant sleep by POC due date.

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 7 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(2)(A)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Labored breathing.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe infants sleep log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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2
3
4
Licensee will start implementing documentation of infant sleep by POC due date.
Type A
Section Cited
CCR
102425(j)(2)(B)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe infants sleep log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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2
3
4
Licensee will start implementing documentation of infant sleep by POC due date.

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 8 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(2)(C)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: Infants up to 12 month of age who are sleeping in a position other than on their back.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe infants sleep log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
Licensee will start implementing documentation of infant sleep by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 9 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe a mandated reporter certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
1
2
3
4
Licensee will submit proof of Mandated Reporter training to LPA by POC due date
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
LIcensee will complete LC 9227 by POC due date

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 10 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)(1)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This plan shall be signed and dated by the infant’s authorized representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
LIcensee will complete LC 9227 by POC due date
Type B
Section Cited
CCR
102425(c)(2)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
1
2
3
4
LIcensee will complete LC 9227 by POC due date

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 11 of 23


Document Has Been Signed on 07/26/2022 07:52 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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Based on observation and record review, the licensee did not comply with the section cited above LPAs didn't observe required documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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2
3
4
Licensee will submit proof of required documents to LPA by POC due date
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4

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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Veronica Martinez-GarzaTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 12 of 23