364846098-3-15-2022-09-CC-JGIE-CCJN5Y-20220315101020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364846098
Report Date: 03/15/2022
Date Signed: 03/15/2022 10:11:45 AM

Document Has Been Signed on 03/15/2022 10:11 AM - 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, 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: 2	DATE:	03/15/2022
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	DANIELA RUBALCAVA		TIME COMPLETED:	10:30 AM

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 03/15/2022 Licensing Program Analyst (LPA) Justin Giese arrived to the facility for an announced case management visit. The licensee has applied to increase their capacity to that of a Large Family Child Care Home. Fire Clearance was granted and obtained on 02/25/2022. LPA was granted entry to the facility by Licensee, Daniela Rubalcava. LPA toured the facility inside and out and reviewed records. The following was observed: Normal days and hours of operation are: Monday-Friday, 7:00am to 5:30pm OFF-LIMIT AREAS INCLUDE: Master bedroom, garage, and dog run (partial backyard) • The facility is operating within the licensed capacity and appropriate ratios • The Licensee is present in the home and has ensured that children in care are supervised at this time • When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children • A working telephone is present • Appropriate fire extinguisher, smoke detector and carbon monoxide detector is present and were tested by the applicant during this inspection. • All hazardous items are inaccessible, this includes: detergents, cleaning compounds, medications and other items which could pose a danger to children • Storage of poisons is inaccessible to children and locked • There is a properly barricaded fire place

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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: 03/15/2022

NARRATIVE

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· No stairs - this is a single story home
· Home is clean and orderly, with heating and ventilation for safety and comfort
· Safe and appropriate toys and equipment are present for both indoor and outdoor activities.
· Outdoor play areas are fenced or appropriate supervision is present
· Verification of control of property on file
· Property owner/landlord notification and consent on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Pediatric CPR and First Aid Card expire on 06/27/2023
· Health & Safety Certificate - completed on 06/10/2021
· There are no bodies of water, at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & 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.
· Clean, safe and age appropriate toys
· Documentation of fire drills were last conducted on: 01/26/2022
· Each child’s file contains a copy of the emergency information card with required information

Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed. All individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. This was verified on 03/09/2022

Current facility’s phone numbers must be on file at all times.
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills are to be conducted every six months
- Responsibilities of being a mandated reporter
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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: 03/15/2022

NARRATIVE

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The licensee is urged to visit the U.S. Consumer Product Safety Commission webpage at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled

Once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov.
Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov
Responsibility to know the regulations for anyone providing care
Inaccessibility of hazards must be constantly reassessed depending on the children in care

- Please subscribe to childcareadvocatesprogram@dss.ca.gov to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. This website can also be accessed through www.ccld.ca.gov

- The Duty Officer is available to answer questions Monday – Friday at 1-844-LET-US-NO (1-844-538-8766).

The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

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

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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: 03/15/2022

NARRATIVE

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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-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

Licensee 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.

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

THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS

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

SUPERVISOR'S NAME: Gilbert Sena	TELEPHONE: (951) 782-4200
LICENSING EVALUATOR NAME: Justin Giese	TELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC809 (FAS) - (06/04)

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