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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414196
Report Date: 06/14/2019
Date Signed: 06/14/2019 10:26:56 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, AMBROSEFACILITY NUMBER:
434414196
ADMINISTRATOR:COMMISSARIAT, AMBROSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 744-0535
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 8DATE:
06/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Ambrose CommissariatTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Marilou Monico, made an annual random inspection. Present in the home were licensee, licensee's parents who are visiting from out of the country, licensee's seven-year-old daughter, and 7 daycare children including 2 infants and 5 preschool age. Days and hours of operation are Monday to Friday from 8:15 AM to 6:00 PM. There are two adults living in the home: licensee and her husband.

LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean. There is a fully charged 2A10BC fire extinguisher, working smoke detector, functioning carbon monoxide detector, barricaded stairs, and glass covered fireplace. There is a swimming in the backyard that meets Title 22 Regulations. Off limit areas in the home: entire upstairs and garage. Off limit areas outside the home: swimming pool area and gated side yard. Medications, cleaning compounds, sharp objects are stored out of reach of children. Per licensee, there are no weapons in the home. Six children's files and a helper's file were reviewed. Licensee maintains a current children's roster and fire drill log. LPA obtained copy of children's roster. Licensee has current CPR/First Aid certification with an expiration date of March 2020.

LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. AB 633 was discussed with Licensee. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at www.mandatedreporterca.com. LPA provided licensee with lead safety information sheets and advised her to provide copies to parents.

A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption.

As a result of this inspection, deficiency was cited on the following page:

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: COMMISSARIAT, AMBROSE
FACILITY NUMBER: 434414196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2019
Section Cited
HSC
1596.8662(b)(1)
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MANDATED REPORTER TRAINING - On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training and shall complete renewal every two years following the date on which he or she completed the initial mandated reporter training.
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Licensee states she will submit proof of completion for her and her helper by 07/15/19.
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This requirement is not met as evidenced by: LPA observed that licensee and her helper have not completed the Mandated Reporter Training. This poses a potential risk to Health, Safety 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
LIC809 (FAS) - (06/04)
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