198014215-7-28-2026-33-CC-MRUZ-DWF47J-20260728185114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198014215
Report Date: 07/28/2026
Date Signed: 07/28/2026 06:52:26 PM

Document Has Been Signed on 07/28/2026 06:52 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	RUBALCABA FAMILY CHILD CARE		FACILITY NUMBER:	198014215
ADMINISTRATOR/ DIRECTOR:	RUBALCABA, GRACIELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 604-9050
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90063
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	07/28/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Licensee, Graciela Rubalcaba		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 7/28/2026 at 09:30am, Licensing Program Analyst (LPA) Monica Ruiz arrived at the facility noted above to conduct an unannounced annual random inspection of the licensed facility. LPA presented identification, disclosed the purpose of the inspection to Licensee, and provided the Entrance Checklist - LIC126. Licensee guided LPA on a tour of the facility. There were seven (7) children present during today’s inspection. Licensee states that there are currently 14 children enrolled. The children's roster was reviewed and is current. Adults in the home were discussed, and all have criminal record clearance. Per licensee, the facility’s hours of operation are Monday through Friday, 6:00 am-6pm. Emergency Disaster Plan, License, and Parents’ Rights were observed to be posted on the wall by the front door at the time of inspection. Disaster drill log was also available during today’s inspection; last disaster drill was conducted on 7/7/26. This is a one story home which consists of 3 bedrooms, 1 bathroom, living room, dining room, kitchen, and laundry room. Children use the living room, dining room, kitchen, and 1 bedroom. Per licensee, areas off limits to children and parents include: 2 bedrooms and laundry room. Licensee states there are no pets on the premises and none were observed on this day. LPA observed cots to be stored in the living room and there are play pens for children in care in bedroom #1 to use. Per licensee, the off-limit areas are locked during operating hours. Page 1

Katrina Chicote
Monica Ruiz
	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: RUBALCABA FAMILY CHILD CARE	FACILITY NUMBER: 198014215
	VISIT DATE: 07/28/2026

NARRATIVE

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LPA advised Licensee that Safe Sleep is documented every 15 minutes for each child in care, until the age of two. Licensee states that she does not have infants in care at this time and is not currently providing overnight care.
In order to provide night care (overnight care, less than 24 hours): The provider must remain awake whenever children are awake. The door to the room where the provider is sleeping must remain open when the provider is sleeping. If the sleeping arrangements are not arranged in such a way that the provider can be assured of hearing a child waken, a monitor system must be used, and must be maintained in good working order at all times. Appropriate cribs or beds, complete with adequate and clean bedding and nightclothes, must be available.

Incidental Medical Services (IMS) policy was discussed. Licensee state that she currently does not have children enrolled who require IMS.

For IMS information see PIN 22-02-CCP. 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: 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.

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.

Based on this information, the following deficiencies on the attached LIC 809D 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 & safety.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee, Graciela Rubalcaba.

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NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Monica Ruiz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: RUBALCABA FAMILY CHILD CARE	FACILITY NUMBER: 198014215
	VISIT DATE: 07/28/2026

NARRATIVE

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All areas identified on the facility sketch as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety and comfort of the children. There is a working telephone maintained in the home.
LPA observed age-appropriate toys such as blocks, puzzles, dramatic play equipment, sensory toys and art supplies all free of loose and sharp parts. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible.

Licensee states that there are no poisons in the home. The Licensee does understand that poison must be locked. The Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Personal Rights of children were observed by LPA at time of inspection. Licensee states children do not play outside.

Licensee states that they provide food for children in care and work with Options Food Program.

Licensee states she uses the hallway next to the bathroom as an ill isolation area, to keep children who are sick away from other children in care, until their parents can pick them up. Licensee states she provides a cot for ill child to rest on, or they can use bedroom #1, depending on the number of children in care.

Licensee states there are no weapons or firearms in the home, and none were observed during this inspection. Licensee states there are no pools or bodies of water on the premises, and none were observed on this day.

The valve on the required 2A 10BC fire extinguisher indicates fully charged and was purchased on 7/20/26. Smoke and carbon monoxide detectors were tested at 10:30am and are in operable condition. LPA observed First Aid Kit to be stored in the living room and was inventoried for necessary supplies.
Licensee and Assistant (S1) both have current Pediatric First Aid and CPR. Proof of immunization against pertussis, and measles was readily available during today’s inspection. The Licensee and S1 have also taken Mandated Reporter Training.

- CPR Card valid until: 4/14/2027
- Fire Extinguisher was purchased on: 7/20/2026
- Mandated Reporter AB1207 Completed: 9/27/2026

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NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Monica Ruiz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: RUBALCABA FAMILY CHILD CARE	FACILITY NUMBER: 198014215
	VISIT DATE: 07/28/2026

NARRATIVE

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Licensee does not have a Health and Safety Training certificate for S1 and will receive a Type B deficiency. Licensee states they will enroll S1 in the 16 hour Health and Safety training required for providers and assistants today and will provide proof of certification by the Plan of Correction (POC) due date.

The following were discussed:
Rooms that are off-limits need to be made inaccessible during operating hours. NO smoking, NO infant walkers, NO Johnny jumpers, NO saucer chairs, NO incline sleepers and any other item that falls into that category are permitted in the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when children are present.

AB 1207: Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training.
Website: http://www.mandatedreporterca.com/
http://www.mandatedreporterca.com/
Senate Bill 792: this bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the visit.

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.

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.

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.

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NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Monica Ruiz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2026 06:52 PM - It Cannot Be Edited

Created By: Monica Ruiz On 07/28/2026 at 12:59 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: 07/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(a)(6)

Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply in that Licensee does not have Health & Safety Training certificate for Assistant (S1), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2026
	Plan of Correction
1 2 3 4	Licensee states they will enroll S1 in Health and Safety training course and will send proof of completetion/certificate to Licensing by the POC due date, 8/28/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Katrina Chicote
NAME OF LICENSING PROGRAM MANAGER:

	Monica Ruiz
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC809 (FAS) - (06/04)

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