394500168-1-10-2020-53-CC-SWIS-BKQ3Q2-20200110172625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500168
Report Date: 01/10/2020
Date Signed: 01/10/2020 05:26:30 PM

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:	AMBRIZ, JESSICA		FACILITY NUMBER:	394500168
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	01/10/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:38 PM
MET WITH:	Jessica Ambriz		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Stacey Williams met with applicant Jessica Ambriz for the purpose of a pre-licensing inspection. During today's inspection the Applicant and Applicant's husband and children were present in the home. LPA and Applicant toured the entire home both inside and out. The facility consists of 3 bedrooms, 1 office, 2 bathrooms, living room, dining room, laundry room, detached garage. There is a shop located in the front right side of the house which will remain locked during childcare hours. The shop, detached garage, open door shed, and unoccupied trailer will remain off limits in the front of the home. Additional off limit areas will consist of licensee’s bedroom, master bathroom, and licensee’s daughter’s bedroom. Licensee’s home is on approximately ten acres of land. The front and backyard are unfenced. The backyard covers approximately ten acres with a walnut orchard. Licensee will have one hundred percent supervision when children are in the front yard and designated play area that is surrounded by a portable fence. The backyard and side areas of the front yard will remain off limits at all times. Applicant owns the home. LPA obtained a copy of the deed to show control of property. Applicant is enrolled to take the required Preventative Health and Safety course which includes 1 hour of nutrition. Applicant's CPR and First aid certification was verified (expiration date, 12/2021) LPA reviewed required forms for children's records including immunization card and proposed Safe Sleep Regulation Concepts. LPA also discussed Parent’s Rights form/poster, new regulations were reviewed which include seat belt/booster seat laws, vaccination requirements for staff and children, and smoking prohibition. Incidental Medical Services (IMS) policy was discussed. 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 There were no bodies of water at the home. Applicant stated that there are no weapons in the home. Kitchen cabinets are latched, and cleaning compounds, knives and medications are inaccessible to children. (report continued on next page, LIC809C)

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: AMBRIZ, JESSICA	FACILITY NUMBER: 394500168
	VISIT DATE: 01/10/2020

NARRATIVE

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LPA observed a fire extinguisher and an operational smoke and carbon monoxide detector in the home that meet regulatory standards. LPA advised the applicant that it there are any poisons at the home, all poisons must be locked with a key lock or combination lock.

Applicant has completed the required AB1207 Mandated Reporter training. Applicant understands that the training must be completed once every two years, training is accessible at www.mandatedreporterca.com.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.
Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction.

This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of today, 1/10/2020 licensee is approved for a provisional status license for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2. Applicant will notify LPA once preventative health services course is taken. Final licensure will be complete once preventative health certificate is verified.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

LIC809 (FAS) - (06/04)

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