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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426215563
Report Date: 10/11/2021
Date Signed: 10/11/2021 01:10:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:AMBROSE FAMILY CHILD CAREFACILITY NUMBER:
426215563
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Maribel AmbroseTIME COMPLETED:
01:25 PM
NARRATIVE
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Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 10/11/2021, at 11:53 AM, Licensing Program Analyst (LPA) Martina Jimenez conducted an unannounced Required Annual Inspection of the Ambrose Family Child Care Home. LPA met with Maribel Ambrose, Licensee, the purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 1 child in care at the time of the inspection.

The main day care areas are living room, dining room, kitchen, and bathroom. LPA observed the day care area to be clean and orderly. LPA observed age appropriate books, toy, games, tables and chairs. LPA observed the off-limits areas which include the 2 bedrooms secured with doorknob covers. The backyard is completely fenced. LPA observed age appropriate toys, bikes, play structure and playhouses.

No bodies of water were observed. Licensee stated that there are no weapons/ammunition in the home. Licensee stated she does not hold a foster family license. Sampling of children's records were reviewed. The fire extinguisher was observed and was serviced February 11, 2021. There is a functioning carbon monoxide detector and smoke alarm that meets statutory requirements, they were tested at 12:18pm, and functioning at the time of the visit. Licensee is current with immunization required per SB 792. The last Safety drill was conducted October 11, 2021. Licensee is current with CPR and First Aid which expires November 16, 2021.

Licensee is not providing Incidental Medical Services. Incidental Medical Services (IMS) policy was discussed. 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

This Report Continues on LIC 809C and LIC 809D

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: AMBROSE FAMILY CHILD CARE
FACILITY NUMBER: 426215563
VISIT DATE: 10/11/2021
NARRATIVE
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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: htttp://www.ada.gov/childqanda.htm

Licensee has not completed the Mandated Reporter Training that is required per AB 1207. LPA reviewed the handout "A Child Care Provider's Guide to Safe Sleep" (PIN 20-24) and Effects of Lead Exposure. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided online at www.ccld.ca.gov.



The inspection visit was conducted in Spanish and report was translated in Spanish by LPA Jimenez. Today, deficiency cited under Title 22 Division 12 Appeal rights given. LPA observed licensee post the Notice of Site visit FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: AMBROSE FAMILY CHILD CARE
FACILITY NUMBER: 426215563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited

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1596.8662 Mandated Reporter (3) On and after January 1, 2018, a person who becomes an administrator or employee of a licensed child day care facility shall complete the mandated reporter training ...(c)Current proof of completion for each licensed child care provider...upon request by the department
This requirement was not met, as evidence
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by the following: Based of observation/record review Licensee was unable to provide verify completion or produce a Mandated Reporter training certificate. This poses a potential risks to the health, safety and personal rights of persons in care.
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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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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