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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619633
Report Date: 03/27/2025
Date Signed: 03/27/2025 04:27:02 PM

Document Has Been Signed on 03/27/2025 04:27 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/
DIRECTOR:		RUBALCAVA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 477-9028
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
03/27/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maria RubalcavaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At 2:30pm on 3/27/2025, Licensing Program Analyst (LPA) Matthew Gallo met with licensee Maria Rubalcava for the purpose of an unannounced annual inspection. Upon arrival, LPA observed a total census of 7 children, consisting of 2 infants and 5 preschool children.

Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include 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 on the property. There is a faux fireplace in the play room that does not become hot enough to require fencing. There are no stairs in the home. Outdoor play space is fenced. When inspecting cabinet beneath the kitchen sink, LPA observed that the child safety lock was broken in a way that left cleaning chemicals accessible to children.

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 7 children’s files and observed 15 minute sleep checks for one of the enrolled infants to not be documented. A current roster is being maintained and fire and disaster drills are documented. Current CPR and First Aid certification was verified and expires 11/2025, and AB 1207 Mandated Reporter Training was verified for the licensee and expires 9/2026. Report continues LIC809-C

Mai LorTELEPHONE: (916) 263-5728
Matthew GalloTELEPHONE: (916) 208-3734
DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RUBALCAVA, MARIA
FACILITY NUMBER: 293619633
VISIT DATE: 03/27/2025
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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. LPA also informed licensee 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.


Title 22 deficiencies are cited on the subsequent pages of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.

Exit interview conducted and report was reviewed with the licensee, Maria Rubalcava. 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. A notice of site visit was given and must remain posted for 30 days.

Report continues on 809-C

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

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RUBALCAVA, MARIA
FACILITY NUMBER: 293619633
VISIT DATE: 03/27/2025
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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: Mai LorTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 04:27 PM - It Cannot Be Edited


Created By: Matthew Gallo On 03/27/2025 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RUBALCAVA, MARIA
FACILITY NUMBER: 293619633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to a child safety lock on the cabinet below the kitchen sink being broken, leaving cleaning chemicals accessible to children. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee will replace the broken locks and provide photographs of corrections to LPA. Corrections can be sent to LPA by email at matthew.gallo@dss.ca.gov or by phone at 916-208-3734
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above due to providing care to 7 children alone without an assistant, with none of the children being enrolled in transitional kindergarten or above. This poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee will reduce census to 6 children if they will be providing care by themselves. Licensee also acknowledged that, if they are providing care by themselves, they must follow the capacity requirements of a Small Family Childcare Home. This includes the requirement that, if more than six and up to eight children are present, the seventh child must be attending transitional kindergarten or above, and the eighth child must be at least 6 years old. LPA will return to ensure compliance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mai Lor
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-5728
Matthew Gallo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 208-3734
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 04:27 PM - It Cannot Be Edited


Created By: Matthew Gallo On 03/27/2025 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RUBALCAVA, MARIA
FACILITY NUMBER: 293619633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in the count of 1 out of 2 infants not having 15 minute sleep checks documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Licensee will provide LPA Gallo with photos of the infant's sleep logs for the week of 3/31/2025-4/4/2025 by the POC due date of 4/7/2025. Pictures can be sent by text to 916-208-3734 or by email to matthew.gallo@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mai Lor
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 263-5728
Matthew Gallo
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 208-3734
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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