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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621368
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:44:34 PM

Document Has Been Signed on 10/13/2021 12:44 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:RUIZ, TRICIAFACILITY NUMBER:
393621368
ADMINISTRATOR:RUIZ, TRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 394-4302
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
10/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tricia RuizTIME COMPLETED:
01:00 PM
NARRATIVE
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On 10/13/21 at 11:00 AM LPA Jackson arrived at the home day care for Tricia Ruiz. LPA observed the licensee arrive at 11:15 am. LPA conducted a tour of the home and observed 13 children in care with the assistant and one uncleared adult. Licensee stated that uncleared was just visiting. Based on the observations, a citation is being assessed to the home day care.

Upon receipt of a Type A citation, LPA discussed with the licensee the requirement to post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the 12 months.

An exit interview was conducted and Notice of Site Visit was provided and posted.

SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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Document Has Been Signed on 10/13/2021 12:44 PM - It Cannot Be Edited


Created By: Christopher Jackson On 10/13/2021 at 12:14 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RUIZ, TRICIA
FACILITY NUMBER: 393621368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
102395(a)(1)

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Failure to obtain a California clearance or criminal record exemption, request a transfer of a criminal record clearance or request and be approved for a transfer of an exemption as specified in Section 102370(d) for any individual required to be fingerprinted under Health and Safety Code Section 1596.871
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Licensee stated the uncleared adult will be leaving on the morning of 10/14/21 and would not assist with the child care during the remainder of their stay.
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 prior to allowing the individual to work, reside or volunteer in the facility. This regulation was not met as evidenced by LPA observed an uncleared adult alone in a room supervising children in care. This poses an immediate health and safety 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:Justin L Denton
LICENSING EVALUATOR NAME:Christopher Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


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Document Has Been Signed on 10/13/2021 12:44 PM - It Cannot Be Edited


Created By: Christopher Jackson On 10/13/2021 at 12:20 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RUIZ, TRICIA
FACILITY NUMBER: 393621368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
102416.5(e)

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Upon arrival LPA observed the assistant with 13 children in care. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity
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Licensee arrived at the home placing the facility into compliance.
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requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This poses a potential health and safety 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:Justin L Denton
LICENSING EVALUATOR NAME:Christopher Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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