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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623759
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:47:07 PM

Document Has Been Signed on 11/01/2022 04:47 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:IBARRA, AMELITAFACILITY NUMBER:
343623759
ADMINISTRATOR:IBARRA, AMELITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 427-2521
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Amelita IbarraTIME COMPLETED:
05:05 PM
NARRATIVE
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On 11/01/2022 at approximately 1:15pm, Licensing Program Analysts (LPAs) Arianna Manabat and Carla Polanci met with Licensee for an unannounced annual / one year inspection. During the inspection there were eleven day care children present at the facility being supervised by the facility representative. All individuals subject to criminal background review have obtained a criminal record clearance.

The home is a two-story home and the off-limits areas include the upstairs and garage. The Licensee stated that there are no firearms or bodies of water on the premises. A health and safety inspection was conducted in the areas accessible to children. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPAs observed all the required postings. LPAs advised the facility representative that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPAs did not observe a fireplace within the facility.

LPA's reviewed facility files. A fire drill log was observed, the last fire drill was conducted June 2022. Facility representative understands Mandated and CPR training must be complete every two years. LPA observed children's files. 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 (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

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 in a 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.Report continues on 809C................

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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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Document Has Been Signed on 11/01/2022 04:47 PM - It Cannot Be Edited


Created By: Arianna Manabat On 11/01/2022 at 03:55 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: IBARRA, AMELITA
FACILITY NUMBER: 343623759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(a)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

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 as evidenced by Licensee does not have the alloted amount of cribs for children in care. It was observed that children in care, who are not able to climb out of cribs, are utilizing alternative sleeping devices which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Licensee will order some play pens or cribs and send proof to LPA.
Type A
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as evidenced by: It was observed that a child was present in the garage. As stated on the fire clearance, the garage shall not be used as part of day care. The fire clearance was granted on 5/16/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Will place yellow tape and baby proof handle on door lock. Licensee will not allow children in area.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Arianna Manabat
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2022 04:47 PM - It Cannot Be Edited


Created By: Arianna Manabat On 11/01/2022 at 03:55 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: IBARRA, AMELITA
FACILITY NUMBER: 343623759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as evidenced by: As evidenced by interviews, Licensee does not have a current CPR card as her current card is out of date. Per previous LIC 809, the CPR card is expired as of 2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee will enroll in a course by this date.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

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 Licensee does not have all required documents for assistant present within the home. Assistant needs to complete an EMSA approved CPR training and Mandated Reporter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee will provide EMSA approved card to LPA by POC date.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Arianna Manabat
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2022 04:47 PM - It Cannot Be Edited


Created By: Arianna Manabat On 11/01/2022 at 03:55 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: IBARRA, AMELITA
FACILITY NUMBER: 343623759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

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, It was observed through record review that all of the children did not have immunizations in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee will update files and send to LPA.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

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, as evidence by the absence of children's roster, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee will fill out roster and send to LPA.
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:Natalie Dunaway
LICENSING EVALUATOR NAME:Arianna Manabat
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


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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: IBARRA, AMELITA
FACILITY NUMBER: 343623759
VISIT DATE: 11/01/2022
NARRATIVE
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…… Continued from previous 809 page

LPA discussed the safe sleep regulations with facility representative 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 [facility representative] 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.



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 [email protected]. 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.

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.

LPA Manabat and Polanco informed LICENSEE that this report dated 11/1/22 document(s) two Type A citations which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

LPA Manabat and Polanco informed the facility representative to provide a copy of this licensing report dated 11/1/22 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.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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