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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500168
Report Date: 10/23/2020
Date Signed: 10/28/2020 11:12:03 AM

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, JESSICAFACILITY NUMBER:
394500168
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
10/23/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Jessica Ambriz TIME COMPLETED:
04:29 PM
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On October 23, 2020 at 3:30 PM, Licensing Program Analyst (LPA), Stacey Williams met with Licensee, Jessica Ambriz via FaceTime video conferencing due to the COVID-19 pandemic. The purpose of the tele-visit was to conduct an increase of capacity inspection. Licensee applied to change from a Small Family Child Care Home to a Large Family Child Care Home. LPA observed 6 daycare children present in the home with Licensee and her daughter. All adults have criminal record clearances.

LPA and Licensee toured the home. The home 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 the office, all bedrooms including licensee’s bedroom, master 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. The backyard and side areas of the front yard will remain off limits at all times.
Licensee acknowledged that children may never enter the off-limit areas. Licensee acknowledged that if she would like to change an off-limits area to on-limits, she will inform LPA for inspection and approval prior to using the space. There are no new residents in the home since licensure.

LPA and Licensee conducted a health and safety tour inside and out the home. A functioning smoke and carbon monoxide detectors and fire extinguisher were observed in the home. The Fire Safety Inspection Clearance has been cleared by Waterloo – Morada Rural Fire Prevention Department as of 8/3/20.

REPORT CONTINUED ON NEXT PAGE

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
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: 10/23/2020
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LPA observed that there were no hazardous items accessible to children. Licensee stated that she understands that any poisons must be kept under lock and key. LPA observed that cleaning materials were inaccessible. Licensee stated there are no weapons in the home. Toys appear to be safe. The backyard has a fenced patio deck.

This facility evaluation report was reviewed and discussed with the Licensee. Records, postings and reporting requirements were discussed. LPA discussed safe sleep regulations and COVID-19 Update Guidance: Childcare Programs and Providers as well as Licensee’s current best practices regarding sanitizing the home, hand washings and wearing face coverings. Licensee was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, self-assessment guides, regulations and legislation pertaining to family child care homes.

Effective today 10/23/20, facility is approved for a provisional license for a Large Family Child Care License to serve 12 children (when there is an assistant present) with no more than 4 infants, or capacity of 14 children when 1 child is enrolled in Transitional Kindergarten or above and 1 child at least age 6 with a maximum of 3 infants. Without assistant, the ratios revert to those for small family childcare home. Provisional license will transfer to regular licensure on 1/11/21.

An exit interview was conducted, and Notice of Site Visit was provided.

Facility evaluation report was emailed to Licensee for receipt and acknowledgement and signature. Licensee understands she must open the email to send back an acknowledgement of receipt.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
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