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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103810072
Report Date: 08/09/2021
Date Signed: 08/09/2021 02:30:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MENDOTA U.P.S./MENDOTA U.S.D.FACILITY NUMBER:
103810072
ADMINISTRATOR:PEREZ, ARACELIFACILITY TYPE:
850
ADDRESS:195 SMOOT AVETELEPHONE:
(559) 655-1191
CITY:MENDOTASTATE: CAZIP CODE:
93640
CAPACITY:48CENSUS: 28DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Araceli PerezTIME COMPLETED:
02:30 PM
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On 08/09/21, Licensing Program Analyst (LPA) Angelica Slaughter conducted an unannounced annual inspection at the facility. LPA met with Site Supervisor, Araceli Perez, and toured the facility indoors and outdoors. There were no bodies of water, firearms and/or ammunition on the premises. Furniture and equipment were in good condition, free of sharp, loose or pointed parts. Playground equipment was in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space was maintained in a safe condition and was free of hazards. Areas around high climbing equipment and slides have soft, synthetic grass cushioning material to absorb falls. Children's toilets and hand washing facilities were sanitary and in good operating condition. Floors in the facility were clean and safe. All kitchen, food preparation and storage areas were clean and free of litter/rubbish. The facility was free of flies, insects, and rodents/vermin. Currently meals are prepared and brought in from the high school and served in the multipurpose building cafeteria on site. All food was protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers had tight-fitting covers and were in good repair. Menus are posted at least one week in advance where an authorized representative can view them. Drinking water was available both indoors and outdoors. The facility had one or more functioning carbon monoxide detectors that meet statutory requirements.

Capacity and limitations as specified on the license are being maintained. The name of the child care center Site Supervisor or fully qualified teacher(s) designated to act in the Site Supervisor's absence has been reported to the Department. The facility maintains a ratio of one teacher supervising no more than 12 children in care. All children are under supervision, including visual supervision, of a teacher at all times. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. A sample of children's files were reviewed and contained contact information for authorized representative and/or relatives or others who can assume responsibility for the child and a medical assessment. LPA also reviewed staff files and observed they contained a health screening, immunization records for influenza, pertussis, and measles and current documentation of completed Mandated Reporter Training. At least one person trained in CPR and pediatric First Aid is present when children are at the facility or at off-site activities.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Angelica SlaughterTELEPHONE: (559) 341-3920
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MENDOTA U.P.S./MENDOTA U.S.D.
FACILITY NUMBER: 103810072
VISIT DATE: 08/09/2021
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Criminal record clearance records are completed as a condition for employment and maintained by the Mendota Unified School District.

This program will operate traditional school year. This facility has an AM and PM sessions. The AM session is from 8:00 AM to 11:00 AM, and the PM session is from 11:30 AM to 2:30 PM; Monday thru Friday.

Incidental Medical Services (IMS) are not currently being provided. Site Supervisor is aware that an IMS plan is required to be submitted to the Licensing Office if they provide any of these services. Information regarding Amercians with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301 (voice), (800) 514-0383 (TDD) and website link https://ww.ada.gov/chilqanda.htm.

LPA and Site Supervisor discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 1 of the California Code of Regulations no deficiencies were observed today.

Exit interview was conducted with the Site Supervisor, Araceli Perez. LPA provided Site Supervisor with a copy of the Facility Evaluation Report (LIC 809), appeal rights, and the Notice of Site Visit form (LIC 9213). The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Angelica SlaughterTELEPHONE: (559) 341-3920
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
LIC809 (FAS) - (06/04)
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