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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500168
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:32:09 PM

Document Has Been Signed on 02/23/2023 02:32 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:AMBRIZ, JESSICAFACILITY NUMBER:
394500168
ADMINISTRATOR:AMBRIZ, JESSICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 608-0039
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Ambriz TIME COMPLETED:
01:00 PM
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On February 23, 2023, Licensing Program Analyst (LPA) Stacey Williams conducted an unannounced 1 Year required inspection and met with Licensee, Jessica Ambriz. LPA observed eleven (11) children (one infant) supervised by Licensee and her two assistants. Criminal record clearances have been verified. Facility fees were reviewed and are current. Licensee stated there are no new residents in the home since licensure. Licensee operates seven day a week and does provide overnight care.

LPA and Licensee toured the facility during the inspection. The facility consists of 3 bedrooms, 1 office, 2 bathrooms, living room, dining room, laundry room, detached garage. There is a shop located in the front right side of the house which will remain locked during childcare hours. The shop, detached garage, and open door shed will remain off limits in the front of the home. Additional off limit areas will consist of kitchen, licensee’s bedroom, master bathroom, and licensee’s daughter’s bedroom. Licensee’s home is on approximately ten acres of land. The front and backyard are unfenced. The backyard covers approximately ten acres with a walnut orchard. Licensee will have one hundred percent supervision when children are in the front yard and designated play area. The backyard and side areas of the front yard will remain off limits at all times.

There are no bodies of water on the property. Licensee stated that there are no weapons in the home. Licensee stated there are no pets in the home.

LPA conducted record reviews during the inspection. Six child files and Licensee and her Assistant’s file was reviewed. All files had the required Licensing documents, consent forms, immunization records in them. LPA discussed mandated reporter training with the Licensee. Licensee understands Mandated Reporter Training is to be completed every two years. Mandated reporter training can be accessed at www.mandatedreporterca.com. Mandated Reporter training certification was current in the Licensee’s file. Mandated Reporter training was not current in Licensee’s two Assistants files. CPR/First Aid certification was reviewed. Expiration date is 11/2023 for Licensee. LPA observed fire drills were conducted at least once every six months and documented.

REPORT CONTINUED ON SUBSEQUENT PAGE, LIC 809 C
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: AMBRIZ, JESSICA
FACILITY NUMBER: 394500168
VISIT DATE: 02/23/2023
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LPA observed that there were no hazardous items accessible to children. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. Toys appear to be safe.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence of the 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.

This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA Information 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 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.


LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the Licensee can obtain updated licensing information, new regulations and access forms. LPA advised Licensee of their responsibility to stay current in regard to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws (CHILDCAREADVOCATESPROGRAM@DSS.CA.GOV)


SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: AMBRIZ, JESSICA
FACILITY NUMBER: 394500168
VISIT DATE: 02/23/2023
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Title 22 Deficiencies were observed in the areas that were evaluated for staff records review concerning mandated reporter training.

LPA reviewed report with the Licensee, Jessica Ambriz and provided copies of the report along with Appeal Rights. A notice of site visit was provided and posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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Document Has Been Signed on 02/23/2023 02:32 PM - It Cannot Be Edited


Created By: Stacey Williams On 02/23/2023 at 01:18 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: AMBRIZ, JESSICA
FACILITY NUMBER: 394500168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Licensee will ensure that her Assistant's (2) complete the mandated reporter training online. Training certificates will be sent to Community Care Licensing by plan of correction date- March 23, 2023.
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:Bettina Engelman
LICENSING EVALUATOR NAME:Stacey Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023


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