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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364819798
Report Date: 06/20/2025
Date Signed: 06/20/2025 02:24:22 PM

Document Has Been Signed on 06/20/2025 02:24 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:INGRAM FAMILY CHILD CAREFACILITY NUMBER:
364819798
ADMINISTRATOR/
DIRECTOR:		INGRAM, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 422-9938
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
06/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:18 PM
MET WITH:Dominique PattersonTIME VISIT/
INSPECTION COMPLETED:
02:37 PM
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On 06/20/2025, Licensing Program Analysts (LPAs) Eric Ramos and Elyse Jones arrived at the facility for a separate matter. LPAs met with assistant Dominique Patterson, toured the facility, took census, and discussed the following.

On a previous inspection conducted by LPAs on May 9, 2025, as the LPAs were approaching the facility they observed the Licensee in the front driver seat of her vehicle with two other adults. LPAs informed the Licensee they were there to see her and asked how long she would be away from the facility. She replied, "Oh ok. I'm not going to be gone for long." The LPAs informed her they would be at the facility when she returned and continued to walk towards the facility. The Licensee got out of the vehicle and walked with the LPAs in the facility. Upon entering the facility the LPAs observed S1 providing Care & Supervision to seven children with no other adults present. During the review of the facility associations the LPAs discovered S1 did not have a Criminal Record Clearance and was not associated to the facility. The Licensee stated S1 began working at the facility on May 5, 2025.

Additionally, the department was informed of an altercation that took place between the Licensee and another individual at the facility during operating hours. It was determined that although children were present during the altercation, there were no daycare children present. Regulation Revocation or Suspension of a License or Registration 102402(a)(3) states the Licensee shall "conduct in the operation or maintenance of a family day care home which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California."
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: INGRAM FAMILY CHILD CARE
FACILITY NUMBER: 364819798
VISIT DATE: 06/20/2025
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Based on information obtained, it has been determined there are violations of Title 22 Regulations.

A civil penalty of $500.00 has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

LPAs Ramos and Jones also informed facility representative Dominique Patterson to provide a copy of this licensing report dated 06/20/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See LIC809-D for cited deficiency.

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.

Exit interview conducted and report was reviewed with facility representative Dominique Patterson .
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Eric Ramos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2025 02:24 PM - It Cannot Be Edited


Created By: Eric Ramos On 06/20/2025 at 12:56 PM
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: INGRAM FAMILY CHILD CARE
FACILITY NUMBER: 364819798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2025
Section Cited
CCR
102370(d)(2)

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(d) All individuals subject to a criminal record [...] shall prior to working [...] (2) Request a transfer of a criminal record clearance as specified in Section 102370(j).

This evidence is not met by:
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Licensee submitted documentation to the Department and LPAs confirmed S1 was associated to the facility on 05/18/2025.

An immediate civil penalty of $500.00 has been assessed.
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Based on observation and interview, S1 had a Criminal Record Clearance but was not associated to the facility which poses an immediate health, safety or personal rights risk to persons 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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Eric Ramos
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2025


LIC809 (FAS) - (06/04)
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