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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400447
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:14:37 PM

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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:RUBIO FAMILY CHILD CAREFACILITY NUMBER:
198400447
ADMINISTRATOR:ELMA RUBIOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 517-3951
CITY:LOS ANGELESSTATE: CAZIP CODE:
90062
CAPACITY:14CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elma Rubio, ApplicantTIME COMPLETED:
03:15 PM
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This is a Pre-licensing inspection conducted on August 20, 2021 at 12:30pm by Licensing Program Analyst (LPA), Alicia Mooberry. The purpose of this inspection is for the pending Change of Location application with the Applicant licensed at #198018596. Elma Rubio, Applicant, took LPA on a tour of the home. Applicant is requesting a large family child care license. Fire clearance was granted on 7/29/2021. Individuals residing in the home were discussed and noted. Per applicant, hours of operation will be Monday to Saturday, 6:00am to 6:00pm. Applicant states that she will care for children 0-13 years of age.

This is a single story home which consists of 3 bedrooms, 1 bathroom, kitchen, living room, and laundry room. The home is located in the rear of a two-unit property. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Per applicant, the children will use the only restroom available in the home, the children will use the rear bedroom as playroom. LPA observed that there is a wall heater in the living room that is made inaccessible by a screen surrounding the heater and anchored to the wall. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. LPA observed that the Applicant had a first-aid kit mounted on the wall inaccessible. The applicant states that there are no poisons in the home. The applicant was advised that any poisons must be locked with a key or combination lock.


Areas used by children include: Living room, Kitchen, 2 bedrooms, and bathroom.
Areas off limits include: Bedroom (located across from bathroom), laundry room, Front unit, back and sides of home, 2 storage units located on the side of the home between the 2 units. LPA observed gates on either side of home making the back of home inaccessible.

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBIO FAMILY CHILD CARE
FACILITY NUMBER: 198400447
VISIT DATE: 08/20/2021
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The home was observed to be clean and orderly with a secure wall heater and portable air-conditioner. There are outlet covers throughout the home. The kitchen cabinets that contain the knives and the cleaning products will be maintained latched at all times. Per Applicant, the cabinets can only unlatch via a magnet which only Applicant will have access to. LPA observed no hazardous items on the floors or within reach, the refrigerator was observed to be clean. Applicant states that the bedroom will stay closed during the hours of operation.
LPA observed age appropriate toys and napping equipment in the facility. LPA observed a portable play yard for infants to nap in. The applicant states she will provide food for children in care. If food is not provided and food is brought from the children’s homes; containers shall be labeled with child’s name and properly stored or refrigerated.

The required (2A10BC) fire extinguisher was observed in the kitchen, with receipt of purchase dated 7/28/21. LPA observed a Smoke and carbon monoxide combo detector, tested and found to be operable. LPA verified that the detector was not on Consumer Product Safety Commission (CPSC) recall list.

Applicant has proof of immunization against pertussis, and measles and has opted out of Influenza. Proof of Mandated Reporter Training (AB1207) on 05/20/21.

Per applicant, the front yard of the home and side and front yard of the Front Unit will be used as outdoor play area. There are cushion area under toys structures. There were no hazards present during inspection. LPA observed. Applicant states children will be supervised at all times during outdoor play time.



Per applicant, there firearms, weapons or bodies of water on the premises. Applicant was advised on water safety.
Applicant has a small dog that will be kept in the locked side yard during the hours of operation.

The applicant has completed the required 8 hour Health and Safety Training, Nutrition and Lead Training on 8/8/21.
Applicant has Pediatric First Aid/CPR on file expired on 06/2021

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBIO FAMILY CHILD CARE
FACILITY NUMBER: 198400447
VISIT DATE: 08/20/2021
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The following was discussed with the applicant:

· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.


· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
-No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility. Smoking on the premises is prohibited.
-All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
-Applicant shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.
-Liability Insurance was discussed. LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBIO FAMILY CHILD CARE
FACILITY NUMBER: 198400447
VISIT DATE: 08/20/2021
NARRATIVE
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FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

INFORMATION TO BE POSTED IN YOUR FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED:
· Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
· Capacity Handout for a Large Family Child Care Home was provided.
· Effects of Lead Exposure: PIN 20-01 CCP
· Guardian User Account Access: PIN 20-20 CCLD
· PIN-20-24-CCP Recently Approved Safe Sleep Regulations in Effect
PIN 21-19-CCP U.S. CONSUMER PRODUCT SAFETY COMMISSION FISHER-PRICE
INFANT EQUIPMENT RECALLS
· PIN 21-18-CCP UPDATED CORONAVIRUS 2019 (COVID-19) INDUSTRY GUIDANCE
FOR CHILD CARE SETTINGS
Per applicant, there are no dual licenses at this address. Applicant’s email address was verified.
The following corrections are needed:
  • Proof of Pediatric First Aid/CPR - Due on 8/30/21


Large family childcare license may be granted upon final review and approval. Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.
Exit interview was conducted with Elma Rubio, Applicant who agrees with the above.
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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBIO FAMILY CHILD CARE
FACILITY NUMBER: 198400447
VISIT DATE: 08/20/2021
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· H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.

· Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Applicant states that they will care for infants. LPA advised the applicant to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. The applicant states infants will sleep in playroom where they will be supervised at all times. LPA provided the applicant with a copy PIN 20-24-CCP Safe Sleep Regulations including LIC 9227 to Applicant and advised to keep Sleep Log for children 12 months and younger.

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

Applicant stated they are receiving regulations and quarterly updates from the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:


CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

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SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Alicia MooberryTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5