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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421887
Report Date: 06/07/2023
Date Signed: 06/07/2023 12:00:06 PM


Document Has Been Signed on 06/07/2023 12:00 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CORDOVA, MERCEDESFACILITY NUMBER:
013421887
ADMINISTRATOR:CORDOVA, MERCEDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 677-5500
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:14CENSUS: 6DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mercedes CordovaTIME COMPLETED:
12:10 PM
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On 6/7/2023 at 9:45am, Licensing Program Analyst (LPA) Catherine Fernandes met with Licensee Mercedes Cordova for an Unannounced Required Annual Inspection. Present during the inspection were four fingerprint cleared helpers, two infants and four preschoolers in care. Residing in the home is Licensee her husband and three adult children. Licensee’s home was toured for a health and safety inspection. The facility operates 7:30am – 5:30pm, Monday - Friday.

The home is a two-story home that consists of five bedrooms and three bathrooms. The home is located in the back 4810 Shattuck ave. The entrance to the day care is the gate on the left side of the house. The inside and outside of the home were observed to be neat, clean with age-appropriate materials and toys for the children. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. During today’s inspection, LPA observed the following precautions, there are safety gates for the stairs in the home and the kitchen to prevent access. Licensee has stated that there are no firearms in the home. There is a pet dog that lives in the home and is around the children.


ON LIMITS AREA: The converted living room that is the main area of the day care, the lower bedroom (nap room), the downstairs bathroom, the enclosed front yard and backyard, the little nook, the mud room and the front room.
OFF LIMITS AREA: the entire second floor of the home, the waterheater room on the first floor, the kitchen and the garage which will be inaccessible by closed and/or locked doors or visual supervision.
ISOLATION AREA: the nook

The home has a fully charged 3A40BC fire extinguisher located on the wall next to the kitchen and a working smoke detector in the hallway and carbon monoxide detector in the main area of the day care.
REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CORDOVA, MERCEDES
FACILITY NUMBER: 013421887
VISIT DATE: 06/07/2023
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Licensee has a working telephone, and all required forms are posted and visible for public view in the childcare room. The push station is located near the front door. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 6/3/2023 The Licensee's CPR and First Aid certificate is current and expires on 10/2023. The Licensee was reminded of the responsibility as a mandated reporter and will provide proof of the required training. LPA did not observe any bodies of water in or near the home. LPA reviewed six the children’s files, three staff files and obtained a current facility roster.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.htm.
NO IMS IS BEING PROVIDED AT THIS TIME.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CORDOVA, MERCEDES
FACILITY NUMBER: 013421887
VISIT DATE: 06/07/2023
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

LPA provided safe sleep pamphlet, a sleep plan, and car seat laws.

Please submit copies for the facility file by 6/19/23:
Immunization for all adults
Mandated report training

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted
Report and Appeal Rights provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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