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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233010701
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:17:36 PM

Document Has Been Signed on 01/08/2025 04:17 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MACIAS BALLESTEROS, ERICKA FCCHFACILITY NUMBER:
233010701
ADMINISTRATOR/
DIRECTOR:		ERICKA MACIAS BALLESTEROSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 391-8785
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
01/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:16 PM
MET WITH:Ericka Macias BallesterosTIME VISIT/
INSPECTION COMPLETED:
04:21 PM
NARRATIVE
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During the course of a complaint investigation inspection, Licensing Program Analyst (LPA) Robert Maciel interviewed Licensee (LS) Ericka Macias Ballesteros who stated that on 12/20/24, an adult (A2) was present at the facility, assisting the Licensee with childcare.

Review of facility fingerprint clearances revealed that A2 possessed a fingerprint clearance but was not associated to the facility. LPA gave LS a copy of he LIC9182 Criminal Background Clearance Transfer Request form and LS stated she would complete it for A2 and submit it to LPA.

The following violations of the California Code of Regulation (Title 22) were observed during today's visit. (See LIC809D) Appeal rights were given. This report was read and reviewed with Licensee Ericka Macias Ballesteros. A notice of site visit was given and must remain posted for 30 days. Failure to do so will result in an immediate civil penalty of $100.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/08/2025 04:17 PM - It Cannot Be Edited


Created By: Robert Maciel On 01/08/2025 at 03:59 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MACIAS BALLESTEROS, ERICKA FCCH
FACILITY NUMBER: 233010701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2025
Section Cited
CCR
102370(d)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 102370(j)...
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LPA gave Licensee a copy of he LIC9182 Criminal Background Clearance Transfer Request form and LS stated she would complete it for A2 and submit it to LPA by email at robert.maciel@dss.ca.gov.
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This requirement is not met as evidenced by: Based on LPA's interview with Licensee who stated that on 12/20/24, an adult (A2) was present at the facility, assisting the Licensee with childcare.
This poses a potential health, safety, and/or personal rights risk to children in care.
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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.
SUPERVISOR'S NAME:Erin Virrueta
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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