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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010682
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:24:24 PM

Document Has Been Signed on 07/12/2024 02:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HERNANDEZ LOPEZ, RUBISELA FCCHFACILITY NUMBER:
493010682
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 0DATE:
07/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:57 AM
MET WITH:Rubisela "Rubi" Hernandez LopezTIME VISIT/
INSPECTION COMPLETED:
02:26 PM
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A prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Y. Yang. The applicant is requesting a license for a capacity of 08 children. Services will be available Mon- Fri 08:30 AM - 05:30 PM. The applicant understands that 24hr consecutive care is prohibited. The residence is a four bedroom/ three bathroom, dual level home. There are currently three adults living in the home. Applicant 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The applicant provided proof of control of property. The floor and yard plans are verified. The children will have access to the living room, kitchen, dining room, childcare room, and downstairs bathroom. The "off limits" areas of the home include the garage, laundry room, and the home's entire second level, which includes four bedrooms and two bathrooms. These areas will be made inaccessible by door locks, latches, door knob covers, and/or child gates. The home's staircase is gated. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone in the home (applicant's cell phone). The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. The applicant states there are no firearms and ammunition stored on the premises. Applicant states that poisons are not stored on the premises. The regulation that poisons are to be locked using a key or combination lock was reviewed. First Aid supplies will be maintained at the facility. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector. The applicant did not have a carbon monoxide detector or a fire extinguisher rated at least 2-A 10:BC at the time of the inspection. The home's backyard is currently off limits. Applicant was advised that the backyard shall be approved by the Department before it is permitted to be used for childcare. There is no spa, pool, pond, or fountain on the premises and none shall be added without prior approval of the Licensing agency. Continued on LIC 809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HERNANDEZ LOPEZ, RUBISELA FCCH
FACILITY NUMBER: 493010682
VISIT DATE: 07/12/2024
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Incidental Medical Services regulations were reviewed with the applicant. The applicant understands that if Incidental Medical Services are provided, an updated Plan of Operation shall be submitted and on file with the Department. 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. Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property or landlord notification/consent is on file. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented. Children's records to be maintained were reviewed. The children's roster is to remain current at all times.

Unusual Incident Report procedures were explained, to include notification before close of next business day and follow-up with written report within seven days. The applicant will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certifications. The licensee shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. The applicant understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. The applicant clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age 2) that may be cared for and when two of the children in care must be school aged.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage athttps://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. (Continued on LIC809-C)
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HERNANDEZ LOPEZ, RUBISELA FCCH
FACILITY NUMBER: 493010682
VISIT DATE: 07/12/2024
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Smoking is prohibited at all times in any area where child care is provided. The licensee understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice.

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 license-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.

On this date, 07/11/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.



Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.



Exit interview conducted and report was reviewed with the applicant, Rubi Hernandez Lopez. This following items shall be corrected before a small FCCH license is issued:
  1. Applicant shall provide proof of a functioning carbon monoxide detector in the home.
  2. Applicant shall provide proof of a fire extinguisher rated at least 2-A 10:BC in the home.
  3. Applicant shall provide proof of immunity against pertussis.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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