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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014215
Report Date: 07/29/2025
Date Signed: 07/29/2025 03:26:55 PM

Document Has Been Signed on 07/29/2025 03:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:RUBALCABA FAMILY CHILD CAREFACILITY NUMBER:
198014215
ADMINISTRATOR/
DIRECTOR:		RUBALCABA, GRACIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 604-9050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90063
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
07/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Graciela Rubalcaba, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On July 29, 2025, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Annual/Random inspection at the above facility. Upon arrival LPA was greeted by licensee, Graciela Rubalcaba who guided LPA on a tour of the facility. LPAs observed 12 child in care with the licensee. LPA informed the licensee that she is operating out of ratio. Per licensee her spouse stepped out for an errand and will return shortly. Per licensee there are 14 children enrolled. Hours of operation are Monday through Friday, 7:30AM to 5:30PM. Inspection was conducted in Spanish.

This is a one-story home which consists of 3 bedrooms, 1 bathroom, living room, dining room, kitchen, and laundry room. Children use living room, dining room, kitchen, and 1 bedroom. Per licensee, areas off limits to children and parents include: 2 bedrooms and laundry room. Licensee stated there are no pets on the premises. LPA observed napping equipment for children in care in bedroom #1 and living room (cribs/mats).

The home is clean, orderly, comfortable, and well ventilated. Licensee provides breakfast, lunch and snacks. LPA observed a working telephone. LPA observed an operable carbon monoxide and smoke alarm. LPA observed fire extinguisher to be fully charged and serviced.

There are several age-appropriate toys and a first aid kit on the premises. Per the licensee, there are no firearms on the premises. Licensees First Aid and CPR expires on 04/14/2027.

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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.

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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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/29/2025
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LPA reviewed children files; files were found to be complete. LPA reviewed staff files; files were found to be complete. Children and staff names were documented on LIC811 (confidential page).

The licensee has completed the online mandated reporter training at www.mandatedreporterca.com, expires on 09/27/2026. All childcare employees must complete mandated reporter training within 30 days of hire and renew training every two years.



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

Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B.

The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).

The licensee was informed that the presence of adults in the home without Criminal Record Clearance or Exemption will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Appointments can be made for Live Scan at 1-800-315-4507.

Per the licensee, fire and disaster drills are conducted every 6 months; last drill documented and conducted on 07/04/2025.

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/29/2025
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Licensee has the required documents posted in the FCCH; Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394).

The following was discussed with the licensee:


Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. Licensee was reminded that supervision is always required to children in care.

Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.

Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category.

--Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.


-- Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates send directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

The on Duty Worker is available for questions Monday through Friday at (323) 981-3350 from 8:00 AM - 5:00 PM.

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 of the importance of checking for recalled infant

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215
VISIT DATE: 07/29/2025
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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 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.

During the exit interview, the licensee, Graciela Rubalcaba confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was informed of the MyChildCarePlan.org site, 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.

Based on the LPA’s observations and records reviews, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

LPA Ayala informed licensee, Graciela Rubalcaba that this report dated 07/29/2025, documents One Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, and personal rights of children in care.



Also, LPA Ayala informed the licensee to provide a copy of this licensing report dated 07/29/2025, that documents any Type A citation, to parent/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

An exit Interview was conducted, a copy of this report along with Notice of Site visit was provided to the licensee, Graciela Rubalcaba.
NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 03:26 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 07/29/2025 at 03:13 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: RUBALCABA FAMILY CHILD CARE
FACILITY NUMBER: 198014215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interview, the licensee did not comply with the section cited above in licensee was observed to be alone with 12 children. Per licensee, her spouse/assistant stepped out and was returning shortly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
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Licensee will remain in compiance with capacity and ratio.
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.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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