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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336300177
Report Date: 11/22/2021
Date Signed: 11/22/2021 12:16:40 PM

Document Has Been Signed on 11/22/2021 12:16 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:IBARRA FAMILY CHILD CAREFACILITY NUMBER:
336300177
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
11/22/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Sabreena IbarraTIME COMPLETED:
12:25 PM
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On 11/22/2021 and time listed, Licensing Program Analysts (LPAs) Sumayya Habeebulla and Ana Noble arrived at the facility to conduct a Required Annual Inspection. LPAs conducted COVID-19 Screening question prior to entry. 4 of the children in care live in the home. Licensee accompanied LPA Habeebulla on a tour of the facility, inside and out, records were reviewed and the following was observed and/or discussed:
Normal days and hours of operation are: Monday - Friday 5 AM to 9 PM
OFF-LIMIT AREAS INCLUDE: Garage, 2nd Floor, and Backyard
The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection
· A working telephone is present
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the applicant during this inspection.
· All hazardous items are stored inaccessible to children
· Toxins are locked
· No guns or weapons present as stated by the Licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Pediatric CPR and First Aid Card expire on 10/2023
· Health & Safety Certificate - completed on 11/2020
· No bodies of water at this time. Licensee 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.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177
VISIT DATE: 11/22/2021
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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
· There are no toxic plants at this time
· Current roster on file
· Documentation of fire drills NOT on file
· Children’s records are NOT complete
· Employee’s records are complete - NO EMPLOYEES
· 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 indicate that all adults who require caregiver background checks have 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_Disassociations858@dss.ca.gov
· Facility is not currently providing IMS Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided an updated Plan of Operation that includes 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
· For more information on SIDS and Safe Sleep Environments, please visit:
California Department of Public Health – California SIDS Program: http://www.cdph.ca.gov/programs/SIDS/pages/default.aspx
AAP – Safe Sleep Campaign: http://www.healthychildcare.org/sids/html
AAP-Free Training: Reducing the Risk of SIDS in Early Education and Child Care: http://shop.aap.org/Reducing-the-Risk-of-SIDS-in-Early-Education-and-Child-Care
And Caring for our Children, Safe Sleep Practices and SIDS/Suffocation Risk Reduction: http://cfoc/nrckids/org/standardview/spccol/safe_sleep
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177
VISIT DATE: 11/22/2021
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The following was reviewed with the licensee(s):
- 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
- AB2231 (2016) – Increased Civil Penalties, effective July 1, 2017 – For failing to correct a violation the civil penalty is increased to $100 per day for EACH violation until corrected; For failing to correct a repeated violation the civil penalty is increased to $250 immediately assessed , and $100 per day afterwards for EACH repeated violation until corrected; For a Zero Tolerance violation the civil penalty is increased to $500 immediately assess, and $100 per day for EACH violation after that until corrected; For any repeated Zero Tolerance violation the civil penalty is increased to $1,000 immediately assess, and $100 per day afterwards for EACH repeated violation until corrected.
NOTE: Repeat violations are defined as a violation of a previously cited statutory or regulatory Section and/or subsection within 12 months prior.
- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – In accordance with California Health and Safety Code Section 1596.8662 – 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. Applicants must meet requirements as a precondition to licensure. This training is free of cost and available at: www.mandatedreporterca.com/ and are provided in English and Spanish. If no training is made available in a required person’s primary language then those persons shall be exempt from this requirement
- AB2370 – Effective January 1, 2019 – Lead Poisoning – providers are required to provide a lead toxicity prevention handout to parents/guardians of newly enrolled and newly reenrolled children with information on risks and effects of lead poisoning; blood lead testing recommendations and requirements; and options for obtaining blood lead testing, including free and/or discounted testing. There will be a training component of this added to the Preventative Health Training beginning July 1, 2020.
- Access to forms & Regulations for Family Child Care Homes 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
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177
VISIT DATE: 11/22/2021
NARRATIVE
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- Current facility’s phone numbers must be on file at all times.
- 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
- Baby walkers, bouncy seats, exersaucers and other similar items are prohibited
- The Licensee is urged visit the U.S. Consumer Product Safety Commission webpage at www.cpsc.gov to ensure that equipment purchased for the day care has not been recalled
- Once licensed, the 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. A civil penalty of $100 per violation will be assessed for noncompliance.
vAccess to Forms, Title 22 Regulations and Provider Information Notices (PINS) for a Child Care Center are online at www.ccld.ca.gov.

vPlease subscribe at www.childcareadvocatesprogram@dss.ca.gov to receive Department updates. They will be sent directly to your e-mail account once you have set up an account. This website can also be accessed through www.ccld.ca.gov

vThe Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov

vThe Duty Officer is available to answer questions Monday – Friday at 1-844-LET-US-NO (1-844-538-8766).

See LIC809D for cited deficiencies. Appeal rights discussed and a copy of this report was provided to the licensee on this date.

During the exit interview, the LICENSEE,Sabreena Ibarra confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177
VISIT DATE: 11/22/2021
NARRATIVE
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As a REMINDER: when your child(ren) turn 18 years of age, you MUST SUBMIT an updated LIC279, LIC508 and TB Screen, MMR (measles), TDAP (pertussis), and FLU (influenza shot or a written, signed and dated declination) and have your child submit for LIVESCAN background clearance. This also applies to any adult PRIOR to them moving into the home or who currently lives in the home. Also, PRIOR to employment of any adult, you must submit their LIC508, and obtain a background clearance through LIVESCAN; TB screening MMR (measles), TDAP (pertussis), and FLU (influenza shot or a written, signed and dated declination); a copy of their current EMSA CPR & First Aid Cards; and a copy of their Mandated Child Abuse Reporter Certificate.

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS ALONG WITH A COPY OF ALL TYPE A DEFICIENCIES (LIC809D) CITED DURING THIS INSPECTION. A COPY OF ALL TYPE A DEFICIENCIES CITED DURING THIS INSPECTION MUST ALSO BE IMMEDIATELY (WITHIN 24 HOURS OF THE CHILD’S NEXT DAY IN CARE) GIVEN TO THE PARENTS OF ALL CHILDREN ENROLLED IN THE CHILD CARE FACILITY AND ANY CHILDREN ENROLLED INTO THE CHILD CARE FACILITY OVER THE NEXT 12 MONTHS (AT THE TIME OF ENROLLMENT).

A copy of this report was provided to the licensee on this date and must be made available to the public upon request for the next 3 years.
SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2021 12:16 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 11/22/2021 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

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 observation, interviewm and record review, the licensee did not comply with the section cited above in cunducting fire drills and documenting the drills on a log which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee agrees to conduct fire drills every six months and submit a copy of the Emergency Drill to the department by 12/22/21.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 children enrolled in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee agrees to update all the required forms for children's files and send a copy to the department by 12/22/21.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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Document Has Been Signed on 11/22/2021 12:16 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 11/22/2021 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 children enrolled in the facility which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee agrees to update all the required immunizations records of children in care and send a copy to the department by 12/22/21.
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 children enrolled in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee agrees to update all the required forms for children's files and send a copy to the department by 12/22/21.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2021 12:16 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 11/22/2021 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee agrees to update all the required forms for children's files and send a copy to the department by 12/22/21.

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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2021 12:16 PM - It Cannot Be Edited


Created By: Sumayya Habeebulla On 11/22/2021 at 11:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: IBARRA FAMILY CHILD CARE
FACILITY NUMBER: 336300177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 children enrolled in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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2
3
4
Licensee agrees to update all the required forms for children's files and send a copy to the department by 12/22/21.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having a LIC 9227 in file for 1 infant (who is not present today) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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2
3
4
Licensee agrees to update all the required forms for children's files and send a copy to the department by 12/22/21.
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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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