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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566216245
Report Date: 03/07/2022
Date Signed: 03/07/2022 11:46:35 AM

Document Has Been Signed on 03/07/2022 11:46 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:AMBRIZ FAMILY CHILD CAREFACILITY NUMBER:
566216245
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gabriela AmbrizTIME COMPLETED:
12:00 PM
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On March 7, 2022 at 9:30 AM, Licensing Program Analyst (LPA) Betzayra Cervantes conducted an announced Pre-licensing inspection. LPA spoke to applicant Gabriela Ambriz and conducted a COVID-19 risk assessment. All answers indicated no exposure to COVID-19. LPA discussed the nature and purpose of the inspection. Applicant and LPA toured the facility inside and outside. There were no children in care at the time of the inspection.

The home is a three bedroom, two bath single story manufactured home. The applicant will use the living room, family room, kitchen, dining room, one bathroom, and backyard for the day-care. The 3 bedrooms, 1 bathroom, and laundry room are off limits and are made inaccessible to children in care. There are age appropriate toys and furnishings in good condition and free of hazards. LPA observed two locked storage sheds located in the side yard which is off limits. There is a gate on the opposite side of the front porch which leads to the sideyard which will be used for daycare. The backyard is fully enclosed with a fenced wall. Applicant has age appropriate toys in the backyard readily accessible to children. LPA did not observe any toxins/hazardous items accessible to children. The bathroom to be used for children in care was observed to be clean and sanitary.

LPA did not observe any toxins/hazardous items accessible to children. A regulation 2A10BC fire extinguisher was observed with a purchase date of 03/07/2022. Applicant is reminded to service or purchase the fire extinguisher yearly. LPA had applicant test smoke and carbon monoxide detectors in the home and were found operational. All adults in the home are fingerprint cleared.

Continued on 809-C

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: AMBRIZ FAMILY CHILD CARE
FACILITY NUMBER: 566216245
VISIT DATE: 03/07/2022
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LPA observed the home to be orderly. No bodies of water were observed on site. Applicant stated that there are no guns or ammunition in the home. Detergents and cleaning compounds are stored out of reach of children. Medication in the FCCH is stored in an elevated cabinet in the kitchen which is outside the reach of children and in an area made inaccessible to children in care. Toxins and cleaning compounds are also secured. Applicant states the home does not currently have liability insurance. LPA informed applicant that parents will need to sign a waiver for the liability insurance if insurance is not obtained (applicant was provided form- LIC 282).

Applicant's Pediatric First Aid/CPR certificate is valid until 08/23/2023. Applicant's Mandated Reported Training certificate is valid until 09/21/2023. LPA reviewed Manufactured Home Purchase Agreement to verify control of property. Preventative Health and Safety and Nutrition Training completed on 08/28/2021.

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.html

LPA issued the applicant updated samples of state required forms to be kept in the children's records. LPA also discussed and provided Guidelines to Safe Sleep and Effects of Lead Exposure leaflets. Applicant was provided PIN 20-24-CCP - Recently Approved Safe Sleep Regulations In Effect and LIC 9227 (Infant Sleeping Plan). Applicant was informed that baby walkers, jumpers, bouncers, exersaucers, or any similar article are not permitted on the premises during day care hours. Applicant were made aware of the responsibility to know the regulations for Family Child Care Home which can be accessed on-line at www.ccld.ca.gov.



LPA reviewed COVID-19 guidelines/resources with applicant (RAST Technical Assistance Visit completed). LPA also reminded applicant to continue monitoring the CCLD website for COVID-19 updates and guidance.

Continued on 809-C
SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: AMBRIZ FAMILY CHILD CARE
FACILITY NUMBER: 566216245
VISIT DATE: 03/07/2022
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License to operate a Small Family Child Care facility is effective today, 03/07/2022. Once licensed, the licensee is required to comply with the terms and limitations stated on the license.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed in Spanish with applicant, Gabriela Ambriz.

SUPERVISORS NAME: George Mingle
LICENSING EVALUATOR NAME: Betzayra Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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