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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483008335
Report Date: 09/22/2023
Date Signed: 09/22/2023 12:44:27 PM


Document Has Been Signed on 09/22/2023 12:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:AYALA, AMBER FAMILY CHILD CARE HOMEFACILITY NUMBER:
483008335
ADMINISTRATOR:AYALA, AMBERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 712-9556
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 4DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Amber Ayala - LicenseeTIME COMPLETED:
01:00 PM
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A required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. A review of staff records on 09/22/2023 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.


During today’s inspection the home and grounds were toured. The Licensee (LS) and one staff (S1) were supervising four children and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 6:30AM to 6:00PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire second floor and garage and were made inaccessible by means of a child safety gate. The staircase in the family room was barricaded with a child safety gate. The Licensee stated she did not utilize the fireplace during the facility’s hours of operation. The home was clean and orderly and was at a comfortable indoor temperature. There were safe toys available for children. There is a working telephone in the home. Licensee’s EMSA approved pediatric CPR/First Aid certification expire 06/12/2025. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke and carbon monoxide detectors; and a fully charged fire extinguisher rated at least 2A10BC. Licensee stated she did not store firearm(s) or other dangerous weapon(s) on the premise. LPA did not observe any poison(s). Licensee furnished current AB 1207 Mandated Reporter Training certificates and required staff immunization record for herself and S1. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AYALA, AMBER FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008335
VISIT DATE: 09/22/2023
NARRATIVE
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LPA reviewed four children’s (C1-C4) records at 10:50am which revealed the records contained Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information form (LIC 700), Parent Notification of Additional Children in Care (LIC 9150), and Notification of Parent’s Rights (LIC 995A), however; C1-C4 were either missing Immunization Record (IR) and/or IR was not transcribed onto the blue CDPH 286. According to the facility’s disaster drill log, the facility did not conduct an emergency drill within the past six months and the last drill was documented on 08/15/22. The facility roster of the children in care was reviewed and appeared to be complete. There were no bodies of water observed. The Licensee stated she currently did not have any children under 24 months old enrolled into care.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. On this date, 09/22/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AYALA, AMBER FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008335
VISIT DATE: 09/22/2023
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
The Licensee provided proof of control of property.

Exit interview conducted and report was reviewed with the Licensee, Amber Ayala. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. Appeal Rights were provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/22/2023 12:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: AYALA, AMBER FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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 limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the disaster drill log which revealed the facility did not conduct an emergency disaster drill within the past six months. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee stated she would conduct an emergency disaster drill before the POC due date and Licensee intends to document the drill on a log, and submit evidence to prove that a drill had been conducted. Licensee intends to submit her POC to the Department by 10/02/23 via mail, email or fax.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on three children's (C1-C3) records reviewed at 10:50am which revealed C1-C3 were either missing Immunization Record (IR) or IR was not transcribed to the blue CDPH 286. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee stated she intends to obtain any missing Immunization Record(s) and transcribed IR onto the CDPH 286, and Licensee would submit the IR and transcribed CDPH 286 to the Department by 10/02/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & fax: 707-588-5099
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/22/2023 12:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: AYALA, AMBER FAMILY CHILD CARE HOME
FACILITY NUMBER: 483008335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Licensee not furnishing documentation to verify the children's enrollment in school. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Licensee stated she would request and obtain documentation to verify six children's enrollment into school, and Licensee itends to submit evidence to the Department by 10/02/23 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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