364846098-10-12-2021-09-CC-SLOZ-C7QSNM-20211012140142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364846098
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:01:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	RUBALCAVA FAMILY CHILD CARE		FACILITY NUMBER:	364846098
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	10/12/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Daniela Rubalcava		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On date and time listed, Licensing Program Analyst (LPA) Samuel Lopez arrived at the facility to conduct a pre-licensing inspection. Present during this inspection was: Applicant Daniela Rubalcava. LPA toured the facility, inside and out and the following was observed and/or discussed: Normal days and hours of operation are: Monday through Friday; 7:00am to 5:30pm OFF-LIMIT AREAS INCLUDE: Master bedroom, garage, and dog run (partial backyard) · Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the applicant during this inspection. Fire extinguisher, smoke detector and carbon monoxide detector are in working order. · All hazardous items are NOT inaccessible · Toxins locked · No guns or weapons present as of this date. Applicant understands all guns, weapons and ammunition must be key-locked separately and made inaccessible per Title 22 Regulations. · Fireplace is properly screened to prevent access by children · Storage of poisons is inaccessible to children and locked · Verification of control of property on file (viewed grant deed) · Facility Sketch and Emergency Disaster Plan are posted · Mandated Reporter Training completed on 6/30/2021 · Pediatric CPR and First Aid Card - expires on 6/27/2023 · Health & Safety Certificate - completed on 6/10/2021 · There are no bodies of water as of this date. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and spas, and some fountains must be properly covered or fenced per title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position when not in use.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel Lopez	TELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: RUBALCAVA FAMILY CHILD CARE	FACILITY NUMBER: 364846098
	VISIT DATE: 10/12/2021

NARRATIVE

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· There is a two tiered water fountain filled with plants instead of water
· Clean, safe and age appropriate toys
· There are no toxic plants observed at this time
· The Applicant was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 10/12/2021 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
· The Applicant can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

The following was discussed with the applicant(s):

- Pre-Licensing Visit Packet provided (children’s/staff records & posting requirements included)
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited

- LPA discussed the safe sleep regulations with Applicant Daniela Rubalcava and discussed 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 the applicant Daniela Rubalcava 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.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel Lopez	TELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: RUBALCAVA FAMILY CHILD CARE	FACILITY NUMBER: 364846098
	VISIT DATE: 10/12/2021

NARRATIVE

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- Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

- Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

Before licensure, the following needs to be corrected/completed:
1. Debris (sharp rocks) removed or made inaccessible
2. Play structure needs to be anchored
3. Rose bushes and other plants, with thorns, remove or made inaccessible

Once all corrections have been verified, the application for a Small Family Child Care Home will be submitted for approval with a maximum capacity of 6, or 8 with parent notification. Applicant advised that all corrections are due within 30 days or the application may be withdrawn.

The Applicant, Daniela Rubalcava, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the applicant Daniela Rubalcava.

SUPERVISOR'S NAME: Aaron Ross	TELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Samuel Lopez	TELEPHONE: (951) 897-2482
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

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