<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426216483
Report Date: 02/01/2023
Date Signed: 02/02/2023 07:42:45 AM

Document Has Been Signed on 02/02/2023 07:42 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:RUBALCAVA FAMILY CHILD CAREFACILITY NUMBER:
426216483
ADMINISTRATOR:MARIA RUBALCAVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 406-6718
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
02/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria & Leonor Rubalcava and Ana HernandezTIME COMPLETED:
04:30 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 2/1/23 at 2:00 PM, Licensing Program Analyst (LPA) Francisca Velazquez conducted an announced Prelicensing Inspection of the abovementioned home and met with Applicants, Maria and Leonor Rubalcava and Ana Hernandez.. LPA informed Applicant of the nature and purpose of the inspection. LPA notes there are no children on site at the time of the inspection. Applicantsinformed LPA of the intention to maintain operating hours of a Family Child Care Home (FCCH) from, Monday- Saturday from 4:00 AM to 6:00PM. The Applicantsalso Informed LPA of the intention to provide care for children birth to 14 years of age.

LPA toured the interior and exterior of the home with the Applicant. This is a two- story home with four (4) bedrooms and two in a half (2.5) bathrooms, one (1) formal living room, one (1) regular living room, one (1) formal dining room, one (1) regular dining room, kitchen, laundry room, garage and outdoor yard. The home's living rooms, kitchen, dining areas, half (.5) bathroom and outdoor yard will be used for childcare services. Meanwhile, the laundry room, garage and entire second floor are off limits and inaccessible to children in care. LPA observed both living rooms to have fire places that are secured with zip ties. In addition, LPA observed a baby gate located on the first step of the stairway, making the entire second floor inaccessible for children in care.

The FCCH has ample spacing and ventilation for children in care. The restroom that will be used for the children was observed to be clean and free of toxins. In the kitchen, LPA observed sharps are stored in an elevated cabinet in the kitchen that is inaccessible to children in care. Cleaning compounds were observed under the kitchen sink that is locked and secured, and in the laundry room, both area are inaccessible to children in care. Applicants stated that medication for the home is stored in the laundry room in an elevated cabinet that is also inaccessible to children in care.

LPA observed a required fire extinguisher 2A10BC in the home which was purchased on 7/8/22. LPA reminded Applicants of the responsibility to service or purchase a regulation fire extinguisher annually. The home has smoke and carbon monoxide detectors which were tested at 3:05 PM and found to be operable.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: RUBALCAVA FAMILY CHILD CARE
FACILITY NUMBER: 426216483
VISIT DATE: 02/01/2023
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
26
27
28
29
30
31
32
LPA observe the outdoor yard to be completely fenced. LPA observed cement and grass area for the children. LPA observed there is plenty of shading for the children play area. Applicants reported water will be accessible by individual water cups. LPA notes no bodies of water were observed. Applicants reported that there are no guns or ammo in the home.

LPA record review revealed Applicants completed Preventative Health training on 6/5/22 and 8/7/22. Further, Applicants completed Mandated Reporter training on 8/3/22 and 7/6/22, and Pediatric CPR/First Aid (EMSA approved) on 6/5/22 and 8/7/22. LPA reminded Applicants of obligation to maintain current training and certifications. LPA reviewed Applicant's control of property document (Mortgage Deed). Applicant does not have liability insurance for the home as of yet. LPA provided Applicant with Affidavit Regarding Liability Insurance form (LIC 282). Applicant received fire clearance for a large license from Santa Maria Fire Department on 1/27/23.



LPA reviewed with Applicant 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.

Applicants was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 applicant 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 Applicant 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.

CONT 809-C

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: RUBALCAVA FAMILY CHILD CARE
FACILITY NUMBER: 426216483
VISIT DATE: 02/01/2023
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
26
27
28
29
30
31
32
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.

Exit interview conducted and report was reviewed with the Applicants, Maria and Leonor Rubalcava and Ana Hernandez. The home meets Title 22 Division 12 requirements of a large FCCH license. Effective date of license will be noted as the present, 2/1/23. Today's visit and review of report was conducted in Spanish due to Spanish being applicant's primary language.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisca Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3