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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619633
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:46:12 PM


Document Has Been Signed on 10/31/2023 03:46 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Maria RubalcavaTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Matthew Gallo met with Licensee Maria Rubalcava for the purpose of an unannounced required 1-year inspection. Licensee states no others are present in the home today. At 2:40pm, LPA observed a total census of 4 children, including 1 infant under 12 months.

Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Prior to inspection, off-limits areas included master bedroom, garage and basement. During inspection, licensee stated intention to move living room to off-limits. Moving forward, updated off-limit areas are: master bedroom, garage, living room, and basement. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home and LPA did not observe bodies of water at the facility. Toxic and hazardous items are inaccessible to children. There is a faux fireplace in the play room that does not need fencing. There are no stairs in the home. Outdoor play space is fenced.

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 reviewed 4 children’s files and observed them to be complete. A current roster is being maintained and fire and disaster drills are documented. Current CPR and First Aid certification was verified and expires 12/2023, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 11/2024.

(Report continues LIC809-C)

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RUBALCAVA, MARIA
FACILITY NUMBER: 293619633
VISIT DATE: 10/31/2023
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Licensee stated they place infant children on their backs when they are napping. LPA discussed infant sleep plan (LIC 9227) requirement with Licensee, and reviewed 15-minute observation checks of napping infants. LPA further discussed the safe sleep regulations with licensee and referenced the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. 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, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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.

No deficiencies were cited during today’s inspection.



Exit interview conducted and report was reviewed with the licensee Maria Rubalcava. A notice of site visit was given and must remain posted for 30 days. During the exit interview, the licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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