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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515402881
Report Date: 10/14/2021
Date Signed: 10/14/2021 10:24:38 AM

Document Has Been Signed on 10/14/2021 10:24 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:INGRAM FAMILY CHILD CARE HOMEFACILITY NUMBER:
515402881
ADMINISTRATOR:INGRAM, CHRISTY & SHAWNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 671-5162
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
10/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Christy and Shawn IngramTIME COMPLETED:
10:34 AM
NARRATIVE
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Licensing Program Analyst (LPA) Martinez conducted a visit at the facility and met with licensees Christy and Shawn Ingram. It was determined through complaint investigation interviews on 8/10/21 that the licensee, Christy called a child (C1) "stupid" under her breath . LPA Martinez interviewed two witnesses (W1 and W2) on 8/10/21 at 2:50PM who stated they heard the licensee called the child "stupid" under her breath and walked away. The licensee was interviewed on 7/9/21 and denied the situation ever occurred.

The following Title 22 deficiencies are cited on the LIC 809D. Licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit must be posted for 30 Days.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Mikah Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 10/14/2021 10:24 AM - It Cannot Be Edited


Created By: Mikah Martinez On 10/01/2021 at 03:42 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: INGRAM FAMILY CHILD CARE HOME
FACILITY NUMBER: 515402881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/18/2021
Section Cited
CCR
102423(a)(1)

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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:(1) To be treated with dignity in his/her
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The licensee agrees to watch the following CCLD Personal Rights video. Following review should send in writing verification they have reviewed the Personal Rights section of the Title 22 Regulations. https://ccld.childcarevideos.org/
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personal relationship with staff and other persons. This requirement was not met as evidenced by: based on interviews, the licensee did not comply with the section cited above in 1 out of 3 children (C1) which poses a potential health, safety or personal rights risk to persons 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:Erin Virrueta
LICENSING EVALUATOR NAME:Mikah Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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