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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010682
Report Date: 10/23/2024
Date Signed: 10/23/2024 11:27:00 AM

Document Has Been Signed on 10/23/2024 11:27 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, 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: 6CENSUS: 1DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Rubisela "Rubi" Hernandez LopezTIME VISIT/
INSPECTION COMPLETED:
10:53 AM
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A post licensing visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang at the request of the licensee to provide technical assistance and inspect and approve a previously designated off limits area of the premises for childcare use. The licensee is requesting approval to use part of the home's backyard for childcare use. The home's backyard is fully fenced; the side yards are off limits and currently gated. No bodies of water were observed on the premises. The LPA inspected and approved the backyard for childcare use. An updated floor sketch was obtained from the licensee.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Rubi Hernandez Lopez. There were no Title 22 deficiencies cited during today's inspection.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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