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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197412854
Report Date: 02/10/2022
Date Signed: 02/11/2022 08:29:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MONDRAGON FAMILY CHILD CAREFACILITY NUMBER:
197412854
ADMINISTRATOR:MONDRAGON, REYNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 205-7204
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:14CENSUS: 11DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Reyna MondragonTIME COMPLETED:
03:45 PM
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On 2/10/2022, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1 Year inspection at the Mondragon Family Child Care. Upon arrival, the LPA met with the licensee, Reyna Mondragon who guided the LPA on a tour of the facility. Family members residing in the home include 2 adults (licensee, her spouse). Per LIS, facility annual fees are current. All adults living in the home have been background cleared. Per licensee, the hours of operation are Monday through Friday 4:00 a.m. to 5:30 p.m. There were 11 daycare children present during this inspection. Children were napping during the inspection.

The Home is set up as follows:
This is a two-story 3 bedrooms, 3-bathroom home with kitchen/dining, living room, childcare room, and garage. The garage is used for storage only and no childcare activities are conducted there. There is no pool, spa, or other bodies of water on the premises. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The home has central heating and air conditioning. All windows have screens and are free of cracks, bugs, and debris.

Ø Main Area: Main care is provided in the childcare rooms located at the rear of the home. There is one large room (#1) and one smaller room for infants (#2).
· Childcare room: LPA observed age-appropriate toys and furniture for the children. 3 tables were observed with a total of 20 children chairs. Several plastic storage bins were observed in which games and toys are stored for the children. A small play kitchen was located by the door with which children can play. There are games and books on the premises of this facility. There are mats on the floor that have educational/learning activities on them. The mats were observed to be in good condition. LPA observed age-appropriate furniture and toys in the room.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above, the licensee did not documentate 15 minutes check, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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The licensee will email the LPA the log by 2/14/2022
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The licensee was unable to provide her assistant's MMR and DTP and TB ,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2022
Plan of Correction
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The licensee will provide the shot record.
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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. During today's inspectiion, LPA did not observed the assistants have LIC 9052 in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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The licensee will email her assistants' LIC 9052 by 2/14/2022.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. During today inspection, the licensee was still waiting her assistant to provide the Immunized again Pertussis and Measles,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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The licensee will email the documentation to LPA
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: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
VISIT DATE: 02/10/2022
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·Children Bathroom (#1): Children use the bathroom through a door in the large childcare room. Child lock was observed on cabinet under the sink. The Bathroom was toured, and inspected sink/toilet is in operable condition. Toilet and faucets are clean, safe, and operable. All poison and medications are made inaccessible to children with child safety latches on the sink cabinet and drawers. The bathroom was observed to be free and clear of hazardous items. The bathroom was clean, sanitized, and in good repair.
· Bedroom #2 (Infant room): LPA observed 5 cribs and a diaper change table and a storage unit for extra toys.
· Backyard: The backyard was inspected; The backyard is gated all around. The outdoor play area was observed . The backyard is part of daycare. There is a grass and concrete area for active play. There is a large jungle gym with swing that is anchored. On the right side of the yard has many items which need to make them inaccessible to the children. The licensee signed the declaration. she will not allow children to go outside until the area is clean or make it inaccessible to the children

Ø Off-limit: Off limit areas include the home's entire upstairs, kitchen (French doors with safety knob), living room and the garage.

Ø Others:
· AC/Heating Unit was observed. AC/Heating Unit is located on the left side of the home is accessible to children. The licensee needs to make the unit inaccessible to children
· Fireplace: The fireplace was observed in the off-limits living room and is screened.
· Isolation area (Illness): Per licensee, if the child shows sings of illness, he/she will be separated form other children and stay in classroom area but not with children.
· Napping: Children will nap in the designated areas with adult supervision. LPA observed 8 mats in the closet.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
VISIT DATE: 02/10/2022
NARRATIVE
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· The First Aid kit is located under the bathroom sink inaccessible to children. The First Aid Kit was observed complete with supplies and a first aid manual.
· Fire extinguisher (2A10BC): LPA observed there is a required fire extinguisher (2A10BC) fully charged Date: 4/2021 and located in the children bathroom inaccessible to children. It meets standards established by the State Fire Marshall.
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
· Medications and cleaning solutions: Detergents/cleaning compounds are under the kitchen sink with a child locked. Medications are in the off-limits bedroom.
· Weapons or Firearms: Per licensee, there are no weapons or firearms. LPA did not observe any weapons or firearms.
· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
· Bodies of water: Per licensee, there are no bodies of water in the home.
· Phone service: There is a working land line or cell phone
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license with an expiration date of 1/06/25. Licensee has valid vehicle insurance with the expiration date of 04/26/22 and vehicle registration.
· Incidental Medical Services (IMS): 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The Licensee will not be providing IMS to the children at this time.
· Pet: No Pets
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
VISIT DATE: 02/10/2022
NARRATIVE
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Ø Documentation:

· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with expiration date (8/17/2023) and all her assistants also have current CPR/First Aid Training. 1 hour of nutrition training, (8) hours of Preventive Health and Safety Training.
· Immunization: The licensee has the required immunizations. The licensee provided a written statement declining the influenza vaccination.
· Mandated Reporter Training: The licensee has completed the online mandated reporter training at www.mandatedreporterca.com, and will renew 2/5/2024. All her assistants have the Mandated Reporter Training.
· Child files: LPA reviewed 8 children's records, the records are incomplete and missing forms.
OR
LPA observed 8 children's files contained all required licensing documents.
· Staff Personnel File: LPA observed 2 assistants file
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and conducted on 01/20/2021.
· Facility Roster: LPA observed Child Care, Facility Roster. Per Licensing Information System, facility annual fees were current.
· Infant Sleeping Plan (LIC 9227): LPA shared the information with the licensee. Per Licensee, there is 1 infant (11 months) enroll in the facility.
· Licensee has posted as required the Facility License, Emergency Disaster plan, and Parents Rights Poster.
The following information was discussed with the licensee:
ü Mandatory Forms for the children’s files and provider’s files.
ü Requirements for fire drills, earthquake drills, and documentation for both.
ü The role and responsibilities of being a mandated reporter were discussed.
ü The licensee is reminded that 100% supervision is required for children at all
times.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
VISIT DATE: 02/10/2022
NARRATIVE
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ü Capacity requirements, Roster requirements, Posting requirements, Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, and Safe Sleep Awareness. The role and responsibilities of being a mandated reporter were reviewed. The licensee was reminded that supervision is always required for children in care.
ü Licensee was made aware that it is their responsibility to know the regulations as well as anyone who assists in providing care. Licensee was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility’s phone number; if the phone number is changed, licensing must be notified.
ü Licensee was advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
ü The licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hot-line at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
ü Criminal Record Statement: Licensee [or facility representative] 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 the 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.
ü Safe Sleep: LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [facility representative] 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.
ü Notice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
ü Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MONDRAGON FAMILY CHILD CARE
FACILITY NUMBER: 197412854
VISIT DATE: 02/10/2022
NARRATIVE
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ü Type A citation: LPA (name of analyst) informed licensee [or facility representative] (include name) that this report dated (insert visit date) document(s) (number of Type A citation) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA (name of analyst) informed the licensee [or facility representative] to provide a copy of this licensing report dated (insert visit date) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
ü The regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban). State law prohibits baby walkers, bouncy seats, exersaucers, and any other items that fall into that category.
ü --Licensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.
n Our Quarterly updates come out every 3 months they are also now in Spanish please log in to the CCLD website or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov

ü The Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 AM - 5:00 PM.

ü A copy of the Safe Sleep Proposed Regulations was provided to Licensee.

ü LPA provided consultation during the inspection.

Deficiencies cited: (See LIC 809D). The following Type B deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and/or Health & Safety codes.



Exit interview conducted and the report was reviewed with the licensee Reyna Mondragon
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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