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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010682
Report Date: 06/11/2025
Date Signed: 06/11/2025 12:32:56 PM

Document Has Been Signed on 06/11/2025 12:32 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HERNANDEZ LOPEZ, RUBICELA FCCHFACILITY NUMBER:
493010682
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 10CENSUS: 6DATE:
06/11/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Rubicela "Rubi" Hernandez LopezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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A change of capacity inspection- case management inspection was made today by Licensing Program Analyst (LPA) Y. Yang. The licensee is requesting a license for a capacity of 14 children. The fire clearance for the requested capacity was received by the Department on 06/11/25. The licensee will have one year of experience operating her FCCH in July 2025. The licensee provided proof of control of property. The licensee owns the home. Services will be available Mon- Fri 06:30 AM - 06:30 PM. The licensee understands that 24hr consecutive care is prohibited. The residence is a four bedroom/ three bathroom, dual level home. There are three adults living in the home. The licensee was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. The licensee is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.

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 (licensee's cell phone). The sharp knives, cleaning supplies, medicines, will be stored out of the reach of children. The licensee states there are no firearms and ammunition stored on the premises. Licensee 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 have access to age appropriate toys and equipment. The home is equipped with a working smoke detector. The licensee 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 partly on limits; the side yards are off limits and inaccessible.There is no spa, pool, pond, or fountain on the premises and none shall be added without prior approval of the Licensing agency.

The increase of capacity application for a capacity of 14 has been approved and will be effective 07/01/2025. The exit interview has been conducted and this report has been reviewed with the licensee, Rubicela Hernandez Lopez. Notice of Site Visit shall be posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Yang Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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