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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415451
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:47:24 PM

Document Has Been Signed on 09/12/2024 05:47 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:AMBARTSUMOVA, KARINAFACILITY NUMBER:
434415451
ADMINISTRATOR/
DIRECTOR:		KARINA AMBARTSUMOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 306-7090
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Karina AmbartsumovaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Other inspection. LPA met with Licensee Karina Ambartsumova and explained the reason for the inspection. The purpose of this inspection is discuss fingerprints and personal rights. Present during today's inspection were Licensee, her assistant, volunteer, and 12 children.

Licensee stated that the volunteer comes once a week for an hour to teach the children math. LPA observed that the volunteer was with the children in the living room. Licensee did stepped into the living room then went to the kitchen. Volunteer left at 11:26AM. LPA discussed with Licensee that any volunteers need to obtain criminal record clearance and cannot be left alone with the children. 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.


-----------------CONTINUES ON 809 DATED 09/12/2024 PAGE 2-----------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AMBARTSUMOVA, KARINA
FACILITY NUMBER: 434415451
VISIT DATE: 09/12/2024
NARRATIVE
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--------------CONTINUATION OF 809 DATED 09/12/2024 PAGE 1---------------

At 10:54AM, LPA observed that there was a child in the high chair. Child was crying. Another child was later placed on a high chair. Both children were not eating nor had any toys or activities in front of them. At 11:02AM, LPA observed that Assistant provided one of the child toys. At 11:10AM, LPA observed Licensee feeding the two children in the high chair. Licensee did not take children out after feeding. LPA discussed with Licensee that children's personal rights cannot be violated.

As a result of this inspection, Type A citations were issued. A civil penalty of $500 was assessed for caregiver background check. Exit interview conducted and report was reviewed with Licensee Karina Ambartsumova. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee Karina Ambartsumova that this report dated 09/12/2024 documents two Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee to provide a copy of this licensing report dated 09/12/2024 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.

Focus Language International was used to translate report.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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Document Has Been Signed on 09/12/2024 05:47 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/12/2024 at 11:18 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA
FACILITY NUMBER: 434415451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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By POC 09/13/2024, Licensee will have volunteer obtain fingerprints. Licensee understands that volunteer cannot come until their
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Based on observation, volunteer has been coming to the family child care home to teach children math once a week for an hour and does not have fingerprint clearance. This poses an immediate health and safety risk to children in care.
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fingerprints are cleared.
Type A
09/13/2024
Section Cited
CCR101223(a)(3)

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Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature...
This requirement is not met as evidenced by:
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By POC 09/13/2024, Licensee will submit written statement that she understands that children's personal rights cannot be
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Based on observation, at 10:54AM, there was a child in the high chair. Child was crying. Assistant brought a toy for the child at 11:02AM. Licensee did feed the child, but did not take the child out after feeding.This poses an immediate health and safety risk to children in care.
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be violated.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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