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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623759
Report Date: 12/19/2022
Date Signed: 12/27/2022 08:25:35 AM

Document Has Been Signed on 12/27/2022 08:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 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: 9DATE:
12/19/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Amelita IbarraTIME COMPLETED:
04:45 PM
NARRATIVE
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On 12/19/2022, at 2:45pm, Regional Manager (RM) Jennifer Brekke and Licensing Program Analyst (LPA) Arianna Manabat conducted an case management inspection at this Family Child Care Home for the purpose of serving a Temporary Suspension Order (TSO). During this visit, LPA and RM observed Licensee Amelita Ibarra present in the facility. Upon RM and LPA's entry to the facility, nine day-care children were observed in care. RM Jennifer Brekke explained to Licensee Ibarra the purpose of the visit and also explained the contents of the TSO documents.

The following documents are included in the TSO packet: Order for Temporary Suspension of License Prior to Hearing, Statement to Respondent, Government Code sections, Instructions For Licensee about the Summary of Charges, Accusation (License Revocation), Request for Discovery and Notice of Defense (2 copies).

During the case management visit, Licensee Amelita Ibarra was made aware that the facility may not operate after close of business on December 19th, 2022 at 6:00pm. A Notice Closed for Business (LIC9031) was placed on the front door.

Additionally, LPA and RM have found that the Licensee failed to meet reporting requirements as the Licensee attempted to verbally report the incident on Monday December 12th, 2022, four days after the incident. The Licensee also attempted to send written notification to LPA Manabat's email but LPA Manabat did not receive any notification as the Licensee did not use the correct email address. Lastly, the Licensee did not attempt to provide the Regional Office with an Unusual Incident Report (LIC 624B). Based on record review, one Title 22 Deficiency has been issued on the subsequent LIC 809-D page.

A copy of this report was reviewed and given to the Licensee. Appeal rights have been provided.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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 12/27/2022 08:25 AM - It Cannot Be Edited


Created By: Arianna Manabat On 12/19/2022 at 10:17 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: IBARRA, AMELITA
FACILITY NUMBER: 343623759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
102416.2(b)(2)

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102416.2 Reporting Requirements
(2) Any child absence means any instance where a child in care is missing. For example, any child in care who wanders away from the Family Child Care Home, ...shall be reported even if the child is later found safe.
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Licensee will submit an Unusual Incident Report to the Regional Office regarding the incident.
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This requirement was not met as evidenced by the Licensee not submitting verbal or written notification of an unusual incident report regarding absence of supervision to the Regional Office. This poses/posed an potential health and safety risk to children in care.
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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:Roxana Saravia
LICENSING EVALUATOR NAME:Arianna Manabat
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022


LIC809 (FAS) - (06/04)
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