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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621368
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:07:52 AM


Document Has Been Signed on 04/13/2023 10:07 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:RUIZ, TRICIAFACILITY NUMBER:
393621368
ADMINISTRATOR:RUIZ, TRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 394-4302
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:14CENSUS: DATE:
04/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tricia RuizTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Erwin Tjhia conducted an unannounced Case Management inspection to verify the removal of an excluded individual, Elizabeth Solomon. Present in the facility was 3 staff and 12 children.

LPA inspected the entire home inside and out and Licensee stated that she understands this person is not permitted to be in the home or on the premises at any time when children are in care.

LPA provided LIC995B (Family Child Care Home Addendum to Notification of Parents' Rights-Regarding Removal/ Exclusion) to Licensee. Licensee was informed that every parent of currently enrolled children have to sign the LIC 995B form and signed copy must be filed in each child's file.

Based on evidence obtained during today's inspection, LPA have verified the individual is not present, employed or residing at the facility.

*No deficiencies cited today under Title 22 Division 12 of the Ca. Code of Regulations*.

This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin TjhiaTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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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