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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845425
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:03:37 PM

Document Has Been Signed on 12/04/2023 12:03 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:PENA-BRISENO FAMILY CHILD CAREFACILITY NUMBER:
334845425
ADMINISTRATOR:PENA-BRISENO,AMBARFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-8800
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 4DATE:
12/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Licensee Ambar Pena BrisenoTIME COMPLETED:
12:10 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 the above date and time, Licensing Program Analyst (LPA) Susan Brewer, arrived at the facility for the purpose of conducting a Case Management inspection regarding a self-reported incident. In addition, the LPA conducted an inspection and review of records regarding deficiencies issued during annual inspection on 10/31/2023. LPA was greeted by the licensee Ambar Pena Briseno and granted entry to tour the facility inside and out. Present were the licensee's spouse and 1 minor resident. LPA took a census of 4 daycare children present. The following was discussed.

On 11/17/2023 the licensee submitted a self-reported incident regarding a client that dis-enrolled due to their unwillingness to return to the daycare facility and a follow-up dispute with the authorized representative regarding fees. The LPA reviewed facility records were reviewed and conducted interviews. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

Plan of Corrections verified and cleared on 12/04/2023:
1. Type A, Operation of A Family Child Care Home 102417(g)(4), temporary lock placed on 10/31/2023. On today's date, LPA verified a new combination lock was installed on hallway closet doors. LPA observed the signed LIC9224 records on file.
2. Type B Infant Safe Sleep 102425(b), Statement of understanding Infant Safe Sleep standards received by Ambar Pena - Briseno. On today's date LPA verified the licensee is in compliance, no loose articles in cribs or play yards.
3. Type B Immunizations 102418(g), record verified in child's file.
4. Type B Child's Records 102421(a)(1), LIC995A record verified in child's file.
5. Type B Infant Safe Sleep 102425(j)(2)(D)(c), 15 minute check verified for Nov. 2023 and Dec. 2023.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425
VISIT DATE: 12/04/2023
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
Plan of Corrections Pending with extended due date: 12/12/2023
6. Administration of Child Day Care Licensing 1597.622(c); POC extended to 12/11/2023 for proof of immunization records for staff.
7. Personnel Requirements 102416(c); 3 staff started Part 1 of training on 11/11/2023 and pending completion 12/11/2023.
8. Personnel Records 102416.1(d), pending receipt of records.

During the inspection the LPA observed an above ground jacuzzi spa, located in the outdoor area, separate from the designated and fenced daycare play area. The licensee stated the spa was purchased during the First week of November and reported the equipment to be empty and not used at this time. LPA inspected the jacuzzi spa to empty of water and covered. The cover has latches that can be locked for safety if filled with water. The licensee stated at this time the jacuzzi will remain empty.

No citations issued on 12/04/2023

No civil penalties issued on 12/04/2023.

An exit interview was conducted and a copy of this report was provided the licensee Ambar Pena Briseno.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2