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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434414196
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:01:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2022 and conducted by Evaluator James G Santos
COMPLAINT CONTROL NUMBER: 07-CC-20220324093057
FACILITY NAME:COMMISSARIAT, AMBROSEFACILITY NUMBER:
434414196
ADMINISTRATOR:COMMISSARIAT, AMBROSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 744-0535
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 9DATE:
05/11/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ambrose CommissariatTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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1. Uncleared staff provides care and supervision to daycare children.
2. Licensee does not ensure that hazardous items are stored locked and inaccessible to daycare children.
3. Licensee restrains daycare child.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) James Santos conducted an unannounced subsequent complaint visit today and met with Licensee, Ambrose Commissariat. The purpose of today's visit was to deliver the investigation findings for the above allegations.

During the course of the investigation, LPA interviewed the Licensee and inspected certain areas of the daycare home. LPA also obtained and reviewed record of staff.

Based on the interview, observations and record review, the preponderance of evidence standard has been met, therefore the above allegatioins are found to be SUBSTANTIATED.

See LIC9099D page for deficiency cited. Exit interview conducted and copy of this report and appeal rights form provided to the Licensee.

NOTICE OF SITE VISIT WAS ISSUED TO LICENSEE AND WAS INFORMED TO POST THE NOTICE IN A VISIBLE LOCATION OF THE DAY CARE FOR A PERIOD OF 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 07-CC-20220324093057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COMMISSARIAT, AMBROSE
FACILITY NUMBER: 434414196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
102370(d)(1)
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Criminal Record Clearance.
(d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1)Obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee agreed to write a plan to ensure all individuals subject to a criminal record review prior to working, residing, or volunteering in her daycare home must have a California clearance or a criminal record exemption as required by the Department. POC to be submitted to CCL by POC due date.
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This requirement is not met as evidenced by: Based on the interview with the Licensee and record review, a staff worked in the daycare home without a valid criminal record clearance. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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*Civil penalty assessed - $500 Violation.

According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file.
Type A
05/12/2022
Section Cited
CCR
102417(g)(4)
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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 be 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.
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Licensee ageed and understood that all hazaradous items which could pose a danger if readily available to children shall be stored and are inaccessible to children.

*CORRECTED
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This requirement is not met as evidenced by: Based on observation, a knife, a bottle of medication and a bottle of disinfecting alcohol were accessible to children in care. This poses an immediate risk to the Health, Safety or Personal Rights to children 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 07-CC-20220324093057
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COMMISSARIAT, AMBROSE
FACILITY NUMBER: 434414196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
102423(a)(4)
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Operation of a Family Child Care Home
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
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Licensee agreed and understood that each child receiving services from a family child care home shall have certain rights hat shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to:
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(4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidenced by: Based on the interview with the Licensee, a garment belt was used to support a child from falling from the chair during feeding. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.

*CORRECTED
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2022 and conducted by Evaluator James G Santos
COMPLAINT CONTROL NUMBER: 07-CC-20220324093057

FACILITY NAME:COMMISSARIAT, AMBROSEFACILITY NUMBER:
434414196
ADMINISTRATOR:COMMISSARIAT, AMBROSEFACILITY TYPE:
810
ADDRESS:1341 ELSONA CT.TELEPHONE:
(408) 744-0535
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 9DATE:
05/11/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ambrose CommissariatTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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1. Licensee told daycare child to push another daycare child.
2. Licensee inappropriately disciplines daycare children.
3. Licensee yells at daycare children
4. Licensee does not ensure that stairway is gated or barricaded.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) James Santos conducted an unannounced subsequent complaint visit today and met with Licensee, Ambrose Commissariat. The purpose of today's visit was to deliver the investigation findings for the above allegations.

During the course of the investigation, LPA interviewed the Licensee, parents and children. LPA also inspected certain areas of the daycare home

Based on the interviews and observations, there is not enough evidence to prove that the above allegations occurred. Based on the information gathered, the allegation is UNSUBSTANTIATED. A finding that is unsubstantiated means although the allegation may have happened or is valid, the preponderance of evidence do not prove it.

No defficiency cited for the above allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4