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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846697
Report Date: 01/08/2025
Date Signed: 01/08/2025 01:21:20 PM

Document Has Been Signed on 01/08/2025 01:21 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PENA FAMILY CHILD CAREFACILITY NUMBER:
334846697
ADMINISTRATOR/
DIRECTOR:		AMBAR PENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-8800
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 2DATE:
01/08/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Ambar Pena, Licensee/ApplicantTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 01/08/2025 at 8:25 AM, Licensing Program Analyst (LPA) Susan Brewer arrived at the facility announced to conduct a Pre-Licensing inspection. The Applicant Ambar Pena was previously licensed and has relocated to a new facility. Licensing Program Analyst Susan Brewer was greeted by the applicant Ambar Pena and granted entry to tour the facility, inside and out, records were reviewed and the following was observed and/or discussed: Present were the licensee applicant and one adult assistant. During today’s inspection the applicant updated the LIC279 Application form, the LIC610A Emergency Disaster form, and the LIC999A Facility Home sketch with updates to the correct layout and Facility Yard Sketch.

Normal days and hours of operation are: Monday through Friday; 3:00 AM to 6:00 PM
OFF-LIMIT AREAS INCLUDE: Bedrooms 1, 2 and 3; Bathrooms 1 & 2, the Garage, Laundry Room; and South Side Yard. The Kitchen and Great room were inspected for emergency purposes only and the outdoor play access is through the North side yard.

The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted in the report.

· The facility is operating and LPA conducted a census of 2 children in care.
· The Licensee is present in the home and has ensured that children in care are supervised.
· When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children.
· A working telephone is present.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA FAMILY CHILD CARE
FACILITY NUMBER: 334846697
VISIT DATE: 01/08/2025
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· Appropriate fire extinguisher (2A:10BC), smoke detector and carbon monoxide detector are present and were tested by the licensee during this inspection. All in compliance on today's date.
· All hazardous items are NOT inaccessible where Kitchen knives, alcohol, lighters, matches, medications and vitamins unlocked in kitchen cabinets and drawers; hygiene products accessible and/or unsecured in the garage and other areas of the home.
· No guns or weapons present as of this date. LICENSEE UNDERSTANDS ALL GUNS, WEAPONS AND AMMUNITION MUST BE KEY-LOCKED SEPARATELY AND MADE INACCESSIBLE PER TITLE 22 REGULATIONS.
· This is a single-story home and no stairs observed indoors or outdoors.
· No fireplace on the property.
· Verification of control of property on file and viewed by lease.
· Property owner/landlord notification and consent LIC9149 is NOT on file.
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights and other required forms are posted however are not posted for public view.
· Pediatric CPR and First Aid completed on 12/02/2023; Card expires on 12/02/2025
· Health, Safety and Nutrition training certificate dated 12/16/2018; No lead component.
· Mandated Reporter General: 11/03/2023; AB1207 Child Care certificate expires: 01/08/2027.
· Fire clearance received and approved on 01/06/2025; Special conditions: Daycare approved for Bedroom 5, Study and Bath 4 only. LPA inspected Bathroom 3, which is added and approved for daycare.
· There are no bodies of water as of this date. Licensee Ambar Pena understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age-appropriate toys on today’s date.
· There are no toxic plants observed at this time.
· Current roster on file, however is observed to be incomplete.
· Documentation of fire drills on file: Not on file at this time.
· Children’s records are incomplete complete: Missing LIC9224 from 11/20/2024, LIC9227 Sleep Plan Page 2 incomplete for infant in care
· Employee’s records are incomplete: Missing Mandated Reporter Training and verification of Tuberculosis..
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA FAMILY CHILD CARE
FACILITY NUMBER: 334846697
VISIT DATE: 01/08/2025
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· Criminal record clearances are required prior to all adults living or working in a Family Child Care Home. A civil penalty of $100.00 per day the person has been present, may be assessed.
Resident and/or staff records reviewed on 01/08/2025 indicate that all adults who require caregiver background checks have NOT received all required clearances or exemptions.

The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
The Applicant was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
Issued applicant the following: SIDS information and Shaken Baby Syndrome pamphlet

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 22-02-CCP. 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 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: http://www.ada.gov/childqanda.htm

LPA Susan Brewer discussed the safe sleep regulations with Applicant Ambar Pena 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 Applicant 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.

Applicant Ambar Pena, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA FAMILY CHILD CARE
FACILITY NUMBER: 334846697
VISIT DATE: 01/08/2025
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As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279 and TB Screen and have your child submit for LIVESCAN background clearance.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Additionally, The following was discussed with the applicant(s):
- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.
- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov

- Pre-Licensing Visit Packet provided
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter and review training every 2 years:
- Access to forms & Regulations for Family Child Care online at www.ccld.ca.gov
- Responsibility to know the regulations for anyone providing care
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility’s phone numbers must be on file with the licensing office at all times
- Baby walkers, bouncy seats, exer-saucers and other similar items are prohibited.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA FAMILY CHILD CARE
FACILITY NUMBER: 334846697
VISIT DATE: 01/08/2025
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The licensee applicant was reminded that a Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also be posted for 30 days
v The Duty Officer is available to answer questions Mon. – Fri.at 1-844-LET-US-NO (1-844-538-8766).

Before licensure, the following needs to be corrected/completed on or before 02/08/2025:
1. Proof of Preventative Health and Safety Lead Component training
2. Livescan for adult resident (not named on lease) and one new employee.
3. LIC9149 Property owner/landlord notification and consent (Only required if operating up to 14).
4. LIC610A 2nd relocation site.
5. Proof of TB Screening and Mandated Reporter Training for employee.
6. Proof of completed LIC9227 Sleep Plan Page 2 for enrolled infant.
7. Proof of Required postings for public view.
8. Past Due Plan of Corrections for violations and citations issued on 11/20/2024:
a. Three Type A violations due by 11/21/2024 - 102352(f)(1) Definition of a Family Day Care; 102416.5(a) Staffing Ratio and Capacity; 102416(a)(2) Reporting Requirements; LIC9224 forms for clients.
b. One Type B violation due by 11/22/2024 – 102370(d)(1) Criminal Record Clearance
9. Informal Conference to address purpose of relocation and violations determined on 11/20/2024.

Once all corrections have been made, with proof sent to licensing, the application for a Large Family Child Care Home will be submitted for approval with a maximum capacity of 12, or 14 with parent notification. As agreed upon by the licensee, all corrections are due within 30 days. If not received within 30 days from the date of this report, the application may be withdrawn.

During the exit interview, the Applicant confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the Applicant Ambar Pena and copy was provided. No citations were issued and no civil penalties were issued. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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