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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845425
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:35:44 PM

Document Has Been Signed on 10/31/2023 03:35 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PENA-BRISENO FAMILY CHILD CAREFACILITY NUMBER:
334845425
ADMINISTRATOR:PENA-BRISENO,AMBARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-8800
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 14TOTAL ENROLLED CHILDREN: 15CENSUS: 5DATE:
10/31/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Ambar Pena Biseno, LicenseeTIME COMPLETED:
03:45 PM
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On 10/31/2023 at 9:18 AM Licensing Program Analyst (LPA) Susan Brewer arrived at the facility to conduct an annual inspection. LPA rang the Ring doorbell and requested entry. The licensee answered the ring remotely by telephone and stated they were away from the facility. LPA S.Brewer could hear children and adult voices coming from inside of the home. LPA asked if the facility was operating, the licensee confirmed the facility was operating and there were qualified assistants caring for children and they would be home soon. At 9:24 AM the licensee’s spouse pulled up into the driveway, greeted and granted the LPA entry to tour the facility inside and out. LPA reviewed records and observed and/or discussed the following: LPA observed 2 adult residents and 1 assistant. The licensee agrees to update the LIC279 Application form and the LIC610A Emergency Disaster Plan.

Normal days and hours of operation are Monday- Friday, 3:00 AM – 10:00 PM
OFF-LIMIT AREAS INCLUDE: GARAGE, MASTER BED ROOMM/BATH, BEDROOMS 2, 3 & 4, BALAUNDRY/STORAGE ROOM, LIVING RM, KITCHEN, OFFICE ROOM & OFFICE ¾ BATHROOM & UNFENCED AREA OF BACKYARD; BEDROOM 1 IS OPEN TO DAYCARE

The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D.
· The facility is operating within the licensed capacity and appropriate ratios. LPA took a census of 5 children supervised by 2 adults.
· The Licensee arrived at 9:33 AM and ensured that children in care are supervised.
· When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children.
· A working telephone is present.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425
VISIT DATE: 10/31/2023
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· Appropriate fire extinguisher 2A:10BC is in the green, smoke detector and carbon monoxide detector are present and were tested by the Licensee during this inspection on 10/31/2023.
· All hazardous items are NOT inaccessible, this includes detergents, cleaning compounds, medications and other items which could pose a danger to children, located in the hallway closet next to the daycare restroom and across from the children’s napping room. At 10:27 AM, LPA observed soft scrub, miscellaneous vitamins, over the counter medication Nyquil, Tile/bathroom cleaners, lice shampoo, Vicks vapor throat cough drops, children’s Mucinex, sunblock lotions, lysol and Clorox liquid cleaners.
· Storage of poisons is inaccessible to children are NOT locked in the outdoor play area, due to the fencing removed from the designated space. LPA observed protective fencing removed by the licensee, making the outdoor play area accessible to bug killers, miscellaneous tools, nails, fog Worx, construction materials, vehicle solutions. The licensee stated, they use the designated space for different purposes where the fencing is removed temporarily with intention of re-installing the protective fencing to enclose the children’s outdoor activity area at a later date.
· There is a properly barricaded fireplace.
· No guns or weapons present as stated by the Licensee Ambar Pena Briseno. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
· No stairs at the home, it is a one level home.
· Home is clean and orderly, with heating and ventilation for safety and comfort.
· Clean, Safe and age-appropriate toys and equipment are present for both indoor and outdoor activities, At 10:28 the LPA observed 6 cribs and play yards with blankets and pillows inside and 1 play yard with a toy inside. The licensee stated, the blankets and pillows are for children over 2 years of age and they only stored the toy in the play yard for the child under 2 years of age. The licensee removed the toy from the play yard at the time of inspection. At 1:20 PM LPA observed staff place an infant to sleep with a pillow in the play yard. The licensee removed the pillow, in the presence of the LPA, prior to the infant falling asleep.
· Outdoor play areas are fenced and/ or appropriate supervision is present. 10:35 AM, LPA observed the designated play area with fencing removed from the posts, making outdoor supplies accessible to daycare children. The licensee stated fencing was only temporarily removed for a special event and has been off limits to daycare children since 10/20/2023.
· Verification of control of property on file by mortgage statement.
· Pediatric CPR and First Aid Cards expired in 12/2022, for the licensee and staff.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425
VISIT DATE: 10/31/2023
NARRATIVE
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· Health & Safety Certificate - completed on 12/16/2018, No lead component.
· Mandated reporter General Certificate NOT ON FILE; AB 1207 Child Care Expires: 02/10/2024
· Fire clearance: 03/03/2022 approved.
· Documentation of fire & earthquake drills to be conducted every six months: Last drill on October 18, however, the year was unverifiable due to the documentation of years in review crossed out, scribbled, and written over where the document originally documented the 2022 year.
· There are no bodies of water, at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Children’s files are NOT complete; File missing for 1 infant child enrolled and attending for since 08/07/2023; 2 other children enrolled prior to their 2nd birthday were missing sleep logs on file.
· Staff’s files are NOT complete on 10/31/2023, Staff CPR/1st aid card exp 12/05/2023, No immunization records on file. The licensee was unable to provide verification for 1 staff present, stating they were a minor.
· A review of staff records on 10/11/2023 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions, however the licensee failed to report a relative staff member moved into the home as of September 2023.

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.

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425
VISIT DATE: 10/31/2023
NARRATIVE
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Licensee Ambar Pena-Briseno, was reminded that all adults 18 and over living or working in the home, 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. The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov for Riverside Regional Office.

LPA Susan Brewer, discussed the safe sleep regulations with licensee Ambar Pena-Briseno 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 licensee 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

LPA Susan Brewer informed licensee Ambar Pena Briseno, that this report dated 10/31/2023 document(s) 102417(g)(4) Operation of a Child Care Home Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 10/31/2023 03:35 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/31/2023 at 01:55 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in at 10:27 AM, LPA observed soft scrub, miscellaneous vitamins, over the counter medication Nyquil, Tile/bathroom cleaners, lice shampoo, Vicks vapor throat cough drops, children’s Mucinex, sunblock lotions, lysol and Clorox liquid cleaners, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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The licensee made the hallway closet temporarily inaccessible with a combination bicycle lock and agrees to either remove the items from the hallway or place a key lock on the hallway doors, to make the cleaning supplies, medications and other toxic items inaccessible and send proof of the lock on or before 11/01/2023, by photo or video through fax or e-mail
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 10/31/2023 03:35 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/31/2023 at 01:55 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in during today's inspection at 1:20 PM, a child under the age of 2 years old s was observed to be placed in the play yard with a pillow to nap, which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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The licensee agrees to ensure all staff are knowledgeable of the infant safe sleep standards and refrain from placing children to sleep in cribs or play yards with loose articles and/or objects. In addition, the licensee agrees to submit a statement of understanding the infant safe sleep regulations to the department, ensuring they and their staff understand the Title 22 regulations 102425 and submit the statement on or before the close of business day on 11/03/2023.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in a staff member present and caring for children did not have proof of immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The licensee agrees to maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, for a subject staff as well as future employees and keep proof of immunization records in the person's personnel record that is maintained by the family day care home.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 10/31/2023 03:35 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/31/2023 at 01:55 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the licensee and staff left to care for daycare children in their absence failed to renew their CPR/1st aid training after the expiration date in 12/2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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The licensee agrees to submit proof of registration for preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866, through an EMSA aproved vendor and submit proof of completed training for the licensee and staff assigned to care for children in their absence, to the department on or before 11/30/2023.
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in did not ensure that employee files are kept for 2 subject staff left to care for children and for the department representative's record review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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The license agrees to maintain personnel records for all employees and volunteers working with daycare children and provide proof of staff verification records on or before 11/03/2023, by fax, mail or e-mail.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 10/31/2023 03:35 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/31/2023 at 01:55 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in the licensee failed to ensure a daycare child present and enrolled as of 08/07/2023 was immunized, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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4
The licensee agrees to ensure immunization documentation for all daycare children are in each child's file immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled, and provide proof of immunization records for a subject child on or before 11/03/2023, by fax, mail or e-mail.
Type B
Section Cited
CCR
102421(a)(1)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). (1) The licensee shall keep the signed and dated notice form for at least three years following
termination of service to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in the licensee failed to keep a signed copy of the LIC995A Notification of Parent's rights which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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4
The licensee agrees to provide proof of the LIC995A Notification of Parent's Rights form for a subject child on or before 11/03/2023, by fax, mail or e-mail.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 8 of 15
Document Has Been Signed on 10/31/2023 03:35 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/31/2023 at 01:55 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in a subject child in care under the age of 2, did not have proof of infant safe sleep logs, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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2
3
4
The licensee agrees to provide proof of infant safe sleep logs for a subject child on or before 11/03/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
Page: 9 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425
VISIT DATE: 10/31/2023
NARRATIVE
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Also, LPA Susan Brewer informed the licensee Ambar Pena Briseno, to provide a copy of this licensing report dated 10/31/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report LIC 9224, or other written statement, must be placed in the child's file for verification.


Deficiencies for Type A and Type B violations were cited this visit.

Civil Penalties issued this visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Ambar Pena-Briseno.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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