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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619633
Report Date: 07/19/2019
Date Signed: 07/19/2019 09:32:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:RUBALCAVA, MARIAFACILITY NUMBER:
293619633
ADMINISTRATOR:RUBALCAVA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 477-9028
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 4DATE:
07/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria RubalcavaTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Manager (LPM) Keven Peters and Licensing Program Analyst (LPA) Blake Morillas conducted an unannounced Case Management Visit to the facility in order to conduct an Informal meeting with Licensee, Maria Rubalcava. The LPA and LPM informed the Licensee of the reason for the visit.

LPM defined the difference between Non-Compliance and an Informal meeting. LPM advised that the purpose of today's meeting is to help provider gain compliance.

Today's informal meeting was to discuss the Type A citation resulting from Complaint Investigations issued on 7-18-2018 and the Type A citation resulting from the Complaint Investigation issued on 6-6-2017.

LPM discussed the Priority 2 complaint from 2018 (Personal Rights Violation) as well as the complaint from 2017 (Personal Rights Violation).

After the discussion, the Licensee has a firm understanding of personal rights practices as well as the prohibition of corporal punishment.

LPM provided the Licensee with a self-assessment guide and discussed the using the Department website (ccld.ca.gov) for child care updates, current forms, legislation and regulation information.

Report was reviewed with the licensee, exit interview conducted.

Notice of site visit posted.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
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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