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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700142
Report Date: 07/07/2022
Date Signed: 07/08/2022 08:33:06 AM

Document Has Been Signed on 07/08/2022 08:33 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:RUBALLOS FAMILY CHILD CAREFACILITY NUMBER:
367700142
ADMINISTRATOR:LESLIE VERONICA RUBALLOSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 809-2153
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Leslie RuballosTIME COMPLETED:
01:29 PM
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 On 06/07/22 at 110:31 a..m. Licensing Program Analysts (LPA) Esequiel Rodriguez conducted an unannounced annual inspection at the Family Child Care Home to assess the Facility operation of their program and current physical plant status. Also, to evaluate the Facility's continuing ability to meet compliance with California Code of Regulations (CCR) Title 22, Health and Safety requirements, and other applicable State and Licensing Statutory requirements. LPA Rodriguez met with Licensee, Leslie Ruballos and stated the reason for the inspection. The LPA provided a copy of the Entrance checklist form, LIC 126.

LPA Rodriguez told provider that to better assure and promote the health and safety of each individual being cared for in licensed setting, the Community Care Licensing Division's (CCLD) is focusing efforts on three priority areas: Prevention, compliance, and enforcement; Therefore, CCLD launched the Inspection Process Project (IPP) to meet these goals. As a result it developed the Compliance and Regulatory Enforcement (CARE) Tools for the Child Care Program which is being used during today's inspection. These does not impose any new requirement on the provider. At 12:05 p.m. LPA Rodriguez along with the Licensee conducted a walk trough of the inside and outside of the facility along with the entire operation of the Facility.

The Facility license has all the required documentation on file and is clean safe and sanitary. All required items are posted in a prominent place. The CARE Inspection checklist was reviewed with the licensee and completed..

LPA encouraged licensee to continue become familiar with the Community Care Licensing website, CARE Tools and inspection processes by periodically visiting the Inspection Process Project and CARE Tools Website. The page will be updated regularly with information related to the new tools and related documents:
https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
SUPERVISORS NAME: Scott Herring
LICENSING EVALUATOR NAME: Esequiel Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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: 07/07/2022
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 Overall, the Facility is in compliance per Title 22 regulations. During today's inspection the LPA observed no deficiencies that may hinder the health and safety of the children in care. Therefore, no deficiencies were cited

An exit Interview was conducted and a copy of this Report, Children's Record Review form (LIC 857) Review of Staff Records form (LIC 859) and Notice of Site Visit (LIC 9213) were provided to Licensee.
SUPERVISORS NAME: Scott Herring
LICENSING EVALUATOR NAME: Esequiel Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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