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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700142
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:11:22 PM

Document Has Been Signed on 06/28/2022 03:11 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:RUBALLOS FAMILY CHILD CAREFACILITY NUMBER:
367700142
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
06/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Leslie RuballosTIME COMPLETED:
03:26 PM
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Licensing Program Analyst (LPA) Thompson-Miller met with Licensee/Applicant Leslie Ruballos for a Case Management Other - Change of Capacity Increase Prelicensing Inspection for a large child care home license. Fire Clearance granted for 14 children (in file). Upon arrival there are 5 children (one school age, one infant, 3 preschool) in care (one lives in the home). This is a two story 4 bedroom, 3 bathroom home with kitchen, pantry, dining room, living room (child care), family room, laundry room and garage. There is a spa on the premises. Family members residing in the home include four adults (Licensee, Licensee spouse, licensee brother and licensee sister-in-law) and four children Days/hours of operation are Monday through Sunday 5:00AM to 4:30AM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: The home is clean and orderly. The facility entrance is through the front door. Main care is provided in living room (left). Children use the bathroom on the right. Children nap on cots/playpen. Licensee will provide a photo of the gate for the other side of the kitchen to be off limits. Off limit areas include the entire upstairs (Bedrooms #1, #2, #3, #4, laundry room, bathroom #2 and #3), pantry, garage (locked) and laundry. All kitchen cabinet are with magnet locks. During the inspection LPA observed Licensee assistant engaged in activities and one napping child. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (under kitchen cabinet, laundry room), medicines (Off limit bedroom) and hazardous items (sharp knives upper kitchen cabinet) that can pose a danger to children. The smoke detector and carbon monoxide detector are in operable condition. LPA observed the required fire extinguisher (2A10BC) is fully charged. The facility sketch is complete and current, there is working telephone (land line and cell). Fire/earthquake drills complete and maintained current. Roster complete and maintained current. Fireplace screened. Home has central AC and heat.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RUBALLOS FAMILY CHILD CARE
FACILITY NUMBER: 367700142
VISIT DATE: 06/28/2022
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Safe and age appropriate toys, play equipment and materials. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/play equipment were observed on the premises. There are age appropriate napping (cots/playpen) equipment. There are no window cords (tied high) accessible to children.

Bathroom: Bathtub and shower are free of hazards. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet is clean and operable.

Kitchen: The home has a clean and fully stocked clean refrigerator/freezer. No chemicals in the kitchen were observed to be accessible. Breakfast, lunch, snacks and dinner will be provided. Hazardous items (sharp knives), plastic bags and cleaning items locked in cabinet that can pose a danger to children are inaccessible. Food brought from the children’s home shall be labelled and dated.

Outdoor: Children play in the backyard. The play area is clear and clean of debris, play area is fenced and gated all around, play yard is mulch and cement. There is a spa (empty no water, with locks) on the premises. There are two swing sets (slide) that are anchored. There is a Trampoline that is used only for Licensee children, not for child care use (Declaration provided). Also age appropriate toys for children.

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. Licensee has CPR/First Aid 05/19/2024 and Mandated Reporter 04/03/2024. Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RUBALLOS FAMILY CHILD CARE
FACILITY NUMBER: 367700142
VISIT DATE: 06/28/2022
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Documents Provided and or Discussed: Fire Drill Log, Roster, Postings, Safe Sleep and Lead Poisoning flyer's, COVID-19 posters and CDPH Mandate (masking update). Licensee stated currently does have child care insurance.

The following were observed/discussed and or provided: Seat Belt Safety, Safe Sleep poster observed, forms required for children file (LIC311D), Notification of Parents' Rights (PUB394), Roster (LIC9040), License, Staffing and Ratio (capacity limitations handout provided), Emergency and Disaster Information (LIC610A, LIC9148), Lead Flyer Requirement, liability insurance (LIC282) must have signed form on file if no liability insurance. Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.

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

The following was discussed with the Licensee:


Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter (www.mandatedreporterca.com) were reviewed, to be completed every two years; Licensee reminded that 100% supervision is required at all times to children in care; Licensee made aware that it is his/her/their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care. Licensee currently does not have Child Care Insurance. Per Licensee no on smokes in the home. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. Licensee advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RUBALLOS FAMILY CHILD CARE
FACILITY NUMBER: 367700142
VISIT DATE: 06/28/2022
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Licensee advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Licensee advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to part obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Prior to making alterations or additions to a family child care home or grounds, the Licensee shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. Licensee shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.

FCCH
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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RUBALLOS FAMILY CHILD CARE
FACILITY NUMBER: 367700142
VISIT DATE: 06/28/2022
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Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Licensee shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.

LPA discussed the safe sleep regulations with licensee's and also instructed Licensee to visit 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's 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.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: RUBALLOS FAMILY CHILD CARE
FACILITY NUMBER: 367700142
VISIT DATE: 06/28/2022
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PIN 22-01-CCLD Dated 5/23/22
Individuals who hold a criminal record clearance or exemption must notify the Department within ten (10) calendar days of any change to their mailing address to ensure effective communication related to a criminal record clearance or exemption. Providers and Licensees are encouraged to ensure individuals on their employee/staff rosters are aware of this new requirement.
Individuals may update their mailing address with the Department in various ways, including: logging into their Guardian account; sending an email to Guardian@dss.ca.gov; calling the customer service line at 888-422-5669; sending a request to update by fax at (916) 754-4589; or mailing the address change information to:
Care Provider Management Bureau
744 P Street MS T9-15-62
Sacramento, CA 95814
If you have questions regarding this PIN, please contact CPMB at 888-422-5669 or Guardian@dss.ca.gov for assistance.
The Department will convey all new information through PINs. Please sign up to be notified here and visit the Department’s website for the latest PINs.

Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days. Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Ready for licensure for large child care license.
No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm. Exit interview conducted and report was reviewed with Licensee Leslie Ruballos. This report was read and provided to Licensee Leslie Ruballos on this date.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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