<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623759
Report Date: 12/12/2022
Date Signed: 12/12/2022 05:09:53 PM

Document Has Been Signed on 12/12/2022 05:09 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: 10DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Amelita IbarraTIME COMPLETED:
05:30 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
On December 12, 2022, at approximately 1:30 PM, Licensing Program Analysts (LPAs) Amanda Sutter and Arianna Manabat met with Licensee Amelita Ibarra. The purpose of today's inspection was discussed with the Licensee. During the visit LPAs observed 10 children supervised by the Licensee and her Assistant. All individuals subject to criminal background review have obtained a criminal record clearance.

On November 1, 2022, one Type A citation was issued for a deficiency related to Safe Sleep regualtions. Upon arrival at 1:30 PM, LPAs observed ten children napping in the living room area. LPAs observed six sleeping on bean bags, one infant sleeping with a blanket in a pack-n-play, and three children sleeping on the ground. One child was awake. LPAs observed the pack-n-play to be covered with a blanket while the infant (C1), was sleeping. During today's visit Licensee stated that she does not have 15 minute sleep logs for the infants.

On November 1, 2022, one type B citation was issued for a deficiency related to child files. After reviewing all the files of the children present, LPAs observed that six of the children present are infants and under the age of 2 years old. Licensee stated that one child was new and did not have a file. LPAs reviewed nine child files. Five of the nine files observed did not have immunization records. LPAs did not observe the LIC9224 (Acknowledgement of Receipt of Licensing Reports) in nine of the nine files reviewed.

On November 1, 2022, two type B citations were issued for deficiencies related to staff personnel files and licensee's CPR/First Aid certification. LPAs reviewed staff files. Licensee stated that her assistant had not yet completed her mandated reporter training and that she was still "in process." On 11/16/2022, Licensee completed an online CPR/First Aid Course from the American Health Care Academy. Licensee's assistant has a CPR/First Aid certification from the NationalCPRFoundation. LPAs informed licensee that accepted CPR courses must be either EMSA approved, issued by the American Red Cross, or by the American Heart Association. Neither the Licensee's CPR/FIrst Aid certification nor her assistant's certification meet this regulation. CONTINUED ON LIC809C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: 12/12/2022
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
26
27
28
29
30
31
32
Based on the inspection, Title 22 Deficiencies have been issued on the attached on the LIC 809-D pages. The Licensee was informed that this report dated on 12/12/2022 documents three Type A citations which shall be posted for 30 consecutive days. The Licensee shall also provide a copy of this licensing report 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 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.

A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. The Licensee has been provided with appeal rights.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/12/2022 05:09 PM - It Cannot Be Edited


Created By: Amanda Sutter On 12/12/2022 at 03:27 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited
CCR
102425(a)

1
2
3
4
5
6
7
102425 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:
1
2
3
4
5
6
7
LPA Manabat will conduct a proof of correction visit to observe that safe sleep regulations are being followed.
8
9
10
11
12
13
14
Based on observation, four infants were using bean bags as sleeping devices, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
12/13/2022
Section Cited
CCR102416.5(d)(1)

1
2
3
4
5
6
7
102416.5 Staffing Ratio and Capacity (d) For a Large Family Child Care Home, the maximum number of children ...shall be...:
(1) Twelve children, no more than four of whom may be infants
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide LPA Manabat with proof of schedule for the infants and there will be a proof of correction visit.
8
9
10
11
12
13
14
Based on observation, there were six infants at the facility upon LPAs arrival, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/12/2022 05:09 PM - It Cannot Be Edited


Created By: Amanda Sutter On 12/12/2022 at 03:47 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited
CCR
102425(b)

1
2
3
4
5
6
7
102425 Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.
This regulation was not met as evidenced by:
1
2
3
4
5
6
7
LPA Manabat will conduct a proof of correction visit to observe that safe sleep regulations are being followed.
8
9
10
11
12
13
14
Based on observation, one infant was sleeping in a crib with pillows and a blanket, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/12/2022 05:09 PM - It Cannot Be Edited


Created By: Amanda Sutter On 12/12/2022 at 03:53 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
102418(g)

1
2
3
4
5
6
7
102418 Immunizations (g)The licensee shall document each child's immunizations... and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide LPA Manabat will proof of all children's immunization records.
8
9
10
11
12
13
14
Through observations and record review, five of nine chidlren's files did not have immunization records in the file which poses/posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
12/19/2022
Section Cited
CCR102416(c)

1
2
3
4
5
6
7
102416 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:
1
2
3
4
5
6
7
The Licensee will provide LPA Manabat with proof of enrollment in an EMSA approved CPR course.
8
9
10
11
12
13
14
Based on interview and record review the Licensee does not have an EMSA approved CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/12/2022 05:09 PM - It Cannot Be Edited


Created By: Amanda Sutter On 12/12/2022 at 04:14 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
102416.1(a)

1
2
3
4
5
6
7
102416.1 Personnel Records (a) Personnel records shall be maintained on each employee...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide LPA Manabat with evidence of an enrolled EMSA CPR approved course and a completed Mandated Reporter certificate for her assistant
8
9
10
11
12
13
14
Based on interview and record review the Licensee's Assistant does not have an EMSA approved CPR card or a current Mandated Reporter certificate, which poses/posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
12/19/2022
Section Cited
CCR102425(j)(2)

1
2
3
4
5
6
7
102425 Infant Safe Sleep (j) The provider shall supervise infants while they are sleeping and adhere to the following requirements:
(2) The provider shall check and document the following:
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide LPA Manabat with evidence of 15 minute checks/ sleep log for all infants.
8
9
10
11
12
13
14
Based on interview and record review six of six infants do not have a safe sleep log which poses/posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/12/2022 05:09 PM - It Cannot Be Edited


Created By: Amanda Sutter On 12/12/2022 at 04:24 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
HSC
1596.8595(c)(4)

1
2
3
4
5
6
7
1596.8595 Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services (4) The licensee shall keep verification of receipt in each child's file.
1
2
3
4
5
6
7
LPA Manabat will return to observe completed LIC9224 in child files.
8
9
10
11
12
13
14
This regulation was not met as evidenced by:
Based on file review, 9 of the 9 files observed did not have the LIC9224 (Acknowledgement of Receipt of Licensing Reports), which poses an potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Amanda Sutter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 7 of 7