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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274413092
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:32:31 PM


Document Has Been Signed on 08/09/2023 03:32 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CHAVARIN, RUBICELDAFACILITY NUMBER:
274413092
ADMINISTRATOR:CHAVARIN, RUBICELDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 774-2273
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY:14CENSUS: 6DATE:
08/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rubicelda ChavarinTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Fermin Campos-Jaramillo conducted an unannounced annual required inspection to the home today. LPA met with Rubicelda Chavarin, Licensee, and explained the nature of today's inspection to her. Days and hours of operation are Monday to Saturday from 5:00 AM to 6:30 PM. The adults that reside in the home are the Licensee, her brother Rafael, and her adult children Rafael and Susana. Also in the home reside Licensee's minor children ages 17, 15, and 11 years old.
LPA observed there were six children in care during today's inspection, included 4 school age, one infant, and one preschool age. Certification for CPR and First Aid Card for Licensee is current and will expire on 8/28/2023 and for helper's Maria same day.
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA obtained a copy of the children's roster today and it is current. LPA reviewed five children's file and observed file's are complete, including the parent's rights form, and the immunization records form. LPA observed that Licensee has conducted a fire drill, Last fire drill was documented on 5/12/23. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside are: All the second floor which includes four bedrooms and two bathrooms. In the first floor the attached garage is off limits. Off limits areas outside: The right side yard and a storage in the back yard. The home has a back yard and it is fenced, Licensee uses it as playground.
LPA observed licensee keeps two dogs in an off limits part of the home. Licensee stated the dogs are vaccinated.
LPA observed a fully charged 3A40BC fire extinguisher last time serviced on 3/22/23 and at least one working smoke detector. LPA observed the home has a carbon monoxide detector. LPA observed barricaded stairs in the home. LPA observed the home has a barricaded fireplace in one of the child care on limits areas. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.
According with the SB792, Licensee has proof of immunization for herself and for her helper Maria.

*******************Report dated 8/09/23 continues in page 2.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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 4


Document Has Been Signed on 08/09/2023 03:32 PM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CHAVARIN, RUBICELDA
FACILITY NUMBER: 274413092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Licensee is not currently documenting the infants at sleep every 15 minutes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee shall start documenting every 15 minutes check ups when the infant is asleep and continue documenting until the infant turns 2 years old. Licensee will submit a copy of the log for the period 8/10/23 to 8/22/23 and submit a copy of the log to Licensing Program on 8/22/23 or 8/23/23.
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
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Based on record review the licensee did not comply with the section cited above. Licensee has not obtained a signed form LIC9227 from parents of the infant she has in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee shall obtain a signed form lic9227 from the parents of the infant she has in care, and will submit a copy to Licensing Program on or before 8/23/23.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHAVARIN, RUBICELDA
FACILITY NUMBER: 274413092
VISIT DATE: 08/09/2023
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Report dated 8/09/23 continues from page 1.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a helper must be present. Licensee understands in absence of a helper the capacity of her license is reduced in capacity and ratio (age of the children) to a small Family Child Care Home license maximum 8. The Licensee states that she transports children via vehicle and that she understands that children cannot be left in parked vehicles unattended at any time. Licensee uses redirection and communication with children as a form of discipline.

Department website: www.ccld.ca.gov provided to Licensee.

LPA observed licensee has renewed the mandated reporter training on 04/15/2022, LPA referred the Licensee to the Department website: www.mandatedreporterca.com for additional information on the online training.

A review of staff records on 7/18/23 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

Report dated 8/09/23 continues in page 3

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHAVARIN, RUBICELDA
FACILITY NUMBER: 274413092
VISIT DATE: 08/09/2023
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Report dated 8/09/23 continues from page 2.

LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Rubicelda Chavarin confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee Rubicelda Chavarin.

Two type B deficiencies were cited today.

Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

A notice of site visit was given and must remain posted for 30 days

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4