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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845425
Report Date: 03/26/2024
Date Signed: 03/26/2024 05:02:05 PM

Document Has Been Signed on 03/26/2024 05:02 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:AMBAR PENA-BRISENOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-8800
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
03/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Licensee's Spouse Jose Briseno and Licensee Ambar Pena BrisenoTIME COMPLETED:
05:10 PM
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On 03/06/2024 at 1:40 PM, Licensing Program Analyst (LPA) Susan Brewer, to conduct a Case Management Inspection, regarding pending Plan of Corrections. The LPA was greeted and granted entry to tour the facility inside and out.Present were the licensee's spouse and two assistants. A census was taken of 5 children in care and the following was discussed. The licensee was temporarily away from the facility and joined the inspection at 3:00 PM. The licensee agrees to submit updated LIC999A Facility Yard Sketch.

Plan of Corrections Pending:
1. Health and Safety Code: 1597.622(c) LPA verifed immunization records for staff present and working at the facility, for MMR, Tdap, Infuenza or letter to decline.
2. Personnel Records 102416.1(d): LPA verified personnel records on file at the facility for record review, such as the proof of criminal record clearance, LIC9052 Employee Rights, LIC9108 Statement acknowledging the responsibility to report child abuse.

During today's inspection and the LPA reviewed facility records. The licensee was unable to provide proof of the required mandated reporter training certificates for staff supervising children and employed as of November 2023. Per licensee, the employees completed the training, however they were unable to print the documents for record review. The licensee received a reminder of the requirement for new employees on 10/31/2023.

A citation for Type B violation was issued on today's date. No civil penalties were issued.

An exit interview was conducted and his report was provided to the licensee Ambar Pena Briseno.

A notice of site visit was given and must remain posted for 30 days. LPA verified the licensee posted the notice prior to leaving the facility.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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 03/26/2024 05:02 PM - It Cannot Be Edited


Created By: Susan Brewer On 03/26/2024 at 04:23 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: PENA-BRISENO FAMILY CHILD CARE
FACILITY NUMBER: 334845425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
HSC
1596.8662(b)(1)

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(1) On or before March 30, 2018, in part... a licensed child day care provider, administrator, or employee...shall complete the mandated reporter training and renew training every 2 yrs. years the initial mandated reporter training.
This regulation was not met as evidenced by:
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The licensee agrees to submit proof of the required CA Mandated Reporter Training Certificates to the department on or before 04/08/2024, by fax, mail or e-mail.
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Based on LPA record review, the licensee was unable to provide proof of the required California Mandated Reporter Training Certificates for 2 staff employed as of November 2023, also present and caring for children, which is a potiential risk to the health and safety of 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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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