434415451-2-12-2026-07-CC-MMOO-DR92ZN-20260212165036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415451
Report Date: 02/12/2026
Date Signed: 02/12/2026 04:50:50 PM

Document Has Been Signed on 02/12/2026 04:50 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	AMBARTSUMOVA, KARINA		FACILITY NUMBER:	434415451
ADMINISTRATOR/ DIRECTOR:	KARINA AMBARTSUMOVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 306-7090
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 12	DATE:	02/12/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:35 PM
MET WITH:	Karina Ambartsumova		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Marilou Monico, made an unannounced Annual Random inspection. LPA met with Licensee, Karina Ambartsumova, and explained to her the purpose of today's visit. Present in the home when LPA arrived were Licensee's 16-year-old son/helper (S3) and 12 children: 2 infants and 10 preschool age. Licensee received the Entrance Checklist - Family Child Care Homes (LIC 126). Licensee's son(S3) translated the information provided to Licensee in Russian. LPA observed all required posting materials. The daycare is open Monday thru Friday from 8:00 AM to 6:00 PM. Licensee states that there are two adults residing in the home: herself and her husband. Licensee's adult helper (S1) arrived during the inspection. LPA advised Licensee that children residing in the home who turn 18 years old have 30 days from their birthday to obtain fingerprint clearances. LPA toured the indoor and outdoor areas of the home. Fire drill was conducted on January 6, 2026. LPA reviewed and obtained a copy of children's roster. LPA observed a fully charged 2A10BC fire extinguisher that was purchased December 2, 2020, gated kitchen, functioning smoke and carbon monoxide detectors. LPA informed Licensee that fire extinguisher is good for one year from purchase date. Cleaning products, medications, and sharp objects were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas inside the home: 3 bedrooms, 1 bathroom, and garage. Off limit areas outside: left side yard and back garden area. LPA advised licensee to notify Licensing for any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The Licensee was reminded to notify the Department prior to any alterations or additions to the home or grounds. Licensee confirmed that there are no weapons or firearms on the premises. Continuation on next pages:

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
	VISIT DATE: 02/12/2026

NARRATIVE

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Licensee 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, 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.

LPA reviewed six(6) children's files during today's inspection for the following records: Notification of Parents Rights (LIC 995A), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Identification and Emergency Information (LIC 700), Individual Infant Sleeping Plan (LIC 9227) and sleep log for children under 2 years old, and immunizations. The two infants (C1 & C2) do not have the sleep log.

LPA reviewed three helper's files (S1, S2, and S3) for the following records: Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations (measles, pertussis and influenza), TB test, and Mandated Reporter Training. Licensee has immunizations in measles, pertussis and flu. Licensee's CPR/First Aid expires on July 15, 2027. Licensee has current Mandated Reporter Training expiring on September 2, 2027. Licensee was reminded that Mandated Reporter Training must be renewed by all staff every 2 years.

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 reminded 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.

Continuation on next pages:

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
	VISIT DATE: 02/12/2026

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

As a result of this inspection, two Type B deficiencies were cited on the following page.

Exit interview conducted and report was reviewed with Licensee, Karina Ambartsumova. Licensee was provided a copy of appeal rights.

During the exit interview, the Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/12/2026 04:50 PM - It Cannot Be Edited

Created By: Marilou Monico On 02/12/2026 at 04:26 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the 2A10BC fire extinguisher was purchased on 12/02/20. Fire extinguisher is only good for one year from purchase date.
	POC Due Date: 02/20/2026
	Plan of Correction
1 2 3 4	Licensee states that she will purchase a new fire extinguisher and will submit proof of purchase and photo to Licensing by 02/20/26.

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 6 children's files which poses a potential health, safety or personal rights risk to persons in care. Two children (C1 & C2) do not have sleep log.
	POC Due Date: 02/20/2026
	Plan of Correction
1 2 3 4	Licensee states she will submit completed sleep log for the two children and will submit documentation to Licensing by 02/20/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:

	Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

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