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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400447
Report Date: 05/05/2022
Date Signed: 05/05/2022 10:40:16 AM

Document Has Been Signed on 05/05/2022 10:40 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
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: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Elma Rubio, LicenseeTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst, LPA, Alicia Mooberry conducted a case management visit to discuss the Conditional Exemption Approval for Aguileo Meza. LPA and Licensee, Margaret Lister discussed exemption conditions. There were no children present during this visit. The exemption was approved on 5/3/22 with the following conditions:
  • Never Unsupervised - Is never left unsupervised with clients
  • No violation of any licensing laws or regulations
  • No conviction of subsequent crime

The exemption may be rescinded in the event that the individual fails to comply with the conditions

Per licensee, Aguileo Meza will reside in the home but will not work or supervise children in care. Licensee provided a written statement
Licensee stated they will go over the conditions with Aguileo Meza.
Licensee will notify the department if there are any changes to the household
Licensee states they understands the Exemption is public information.

LPA discussed reporting requirements with licensee, including to report any unusual incidents within 24 hours. LPA provided an LIC 279 to licensee to be completed when there is a change in household, hours of operation, contact information or if licensee moves.

Exit interview conducted with licensee Elma Rubio
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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