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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419784
Report Date: 10/04/2023
Date Signed: 10/04/2023 05:16:30 PM


Document Has Been Signed on 10/04/2023 05:16 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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:MENDOZA FAMILY CHILD CAREFACILITY NUMBER:
197419784
ADMINISTRATOR:MENDOZA, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(661) 946-8531
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:14CENSUS: 5DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 AM
MET WITH:Teresa MendozaTIME COMPLETED:
05:15 PM
NARRATIVE
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On 10/04/2023, at 12:30 P.M., Licensing Program Analyst (LPA) Joselito L. Del Mundo conducted an unannounced annual inspection at Mendoza Family Child Care Home to assess its ability to meet compliance with California Code of Regulations (CCR) Title 22, Health, and Safety requirements. LPA Del Mundo met with Licensee, Teresa Mendoza and stated the reason for the inspection. The LPA provided copies of the LIC 126 Entrance Checklist Form, LIC 311D Forms/Records to Keep in the Family Child Care Home, and all records/forms that need to be maintain in the facility. Licensee guided the analyst on a tour of the day care areas. The day care take place in the following area of the home: living room #1 (main care room) and #2, bedroom #1, bathroom, and outdoor play area.

Licensee states the day care hours of operation is 23 hours, seven days a week. Currently living in the home is the licensee and licensee’s spouse. Licensee is currently not providing transportation to children in care. During this visit, LPA observed five children present in the facility and one assistant.

Physical Plant: The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds, medicines and hazardous items that can pose a danger to children. Per licensee, cleaning products and detergents are stored in the licensee’s room in the laundry room (off limits) where they are inaccessible to children. Knives and other sharp items are stored in the lower drawer of the kitchen. LPA observed the kitchen drawer lock is broken. Licensee stated that she will replace the kitchen drawer lock. Per licensee, children use the dining area to eat and get some drinking water. Licensee added that household medications are also stored in the licensee’s room where children do not have any access. Licensee also told LPA that zero medications are currently being provided for the current children in care. Licensee stated that she is providing meals and snacks to children.

The facility is a two-story house. All room upstairs are off limits, and a metal gate is used to barricade the
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/04/2023 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the licensee did not maintain copies of immunization records for child #1 and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee will email copies of immunization records for child #1 and #4 to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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Document Has Been Signed on 10/04/2023 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the licensee did not maintain a copy of LIC 995A Notification of Parent's Rights for child #1 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee will email a copy of the signed parents LIC 995A Notification of Parents’ Rights for child #1 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: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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Document Has Been Signed on 10/04/2023 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not comply with the section cited above in that the licensee did not maintain copies of LIC 282 Affidavit Regarding Liability Insurance for child #1, #2, #3 and #4 which posed a potential Health, Safety or Personal Rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee will email copies of signed parents LIC 282 Affidavit Regarding Liability Insurance for child #1, #2, #3, and #4 to LPA.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care..
POC Due Date: 10/20/2023
Plan of Correction
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Licensee stated she will use the safe sleep log document for infant while they are sleeping and will retain the file for compliance purposes.
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: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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Document Has Been Signed on 10/04/2023 05:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551


FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1796.45
1796.45 TB Testing
(a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment or within seven days after employment to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that assistant #1 do not have TB skin test on file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee will email a copy of assistant #1 TB skin test to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784
VISIT DATE: 10/04/2023
NARRATIVE
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entrance leading upstairs. There is a fireplace in the facility and is covered with a glass door and has a child safety lock. The home has central heating and air conditioning units.

Based on records review, fire/earthquake drills were last conducted on September 15, 2023, at 4:00 P.M. The facility has a fully charge fire extinguisher with a 2-A:10-B:C classification (reading in green, checked at 1:38 P.M.)



LPA observed safe and age-appropriate toys, books, kitchen set toys, tables, chairs, cubbies, highchairs, crib, and other learning materials. Licensee provides six sleeping cots for children to use.

Licensee has first aid kit box stored in the kitchen counter. The smoke detector and carbon monoxide detector are in operable condition (checked at 1:12 P.M.). LPA observed electrical outlets are covered with a plastic plug to prevent access by children in care. Licensee stated that she owns no firearms, and no one smoke in the facility.

Licensee is advised that baby bouncers, saucer chairs, or any recalled and or banned toys or sleep/ play equipment are prohibited on the premises. Licensee is advised to check for fixture, furniture and equipment that have been banned or recalled by the United States Consumer Product Safety Commission.

Bathroom: Toilet, sink and faucet were clean and operable. During the inspection, LPA observed a step stool and potty seats inside the bathroom. LPA did not observed razors and/or sharp objects, shampoos, mouthwash, medications, perfumes, air freshener, nail polish and nail remover that will pose a health and safety risk to children in care.



Currently, the licensee has 26 children enrolled in the facility. Licensee stated that when a child shows signs of illness, he/she is separated from other children in the bedroom #1 of the facility.

Outdoor: The facility has no body of water on the premises. The outdoor play area has a covered patio and has safe age-appropriate toys and play equipment. LPA observed toy houses, slides, water play tables, tables, chairs, and little toy cars. Per licensee, she supervised children while playing outside.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784
VISIT DATE: 10/04/2023
NARRATIVE
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At the time of inspection, Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing on the day of the incident and/or 24 hours of incident by telephone, fax and/or in writing to the Department. Licensee is familiar with the Unusual Incident Report form, LIC624B. The report on unusual incident/injuries can also be mailed to unusualIncidentreport@dss.ca.gov

Review of records to be maintained: LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA reviewed five children’s files, licensee, and assistant’s files. Based on records review, children’s files are incomplete; licensee and assistants have current mandated reporter trainings completed on 02/17/2022, 01/19/2023, and 05/05/2023; CPR/First Aid trainings that were completed on 11/24/2021 and 09/28/2023. Licensee and assistants have proof of immunization against measles, pertussis, and influenza. Licensee and assistant #2 have TB skin test on file. However, assistant #1 do not have TB skin test on file.

Licensee and other adults working at the facility have received criminal record clearance.

The following was discussed with the licensee:

Licensee reminded that 100% supervision is required at all times to children in care. Licensee was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified.



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.

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
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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
PALMDALE CHILD CARE, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197419784
VISIT DATE: 10/04/2023
NARRATIVE
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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.

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

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

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

The facility is not in compliance per Title 22 regulations. During today's inspection, LPA Del Mundo observed deficiencies that may hinder the health and safety of the children in care. Type B deficiencies were cited during this inspection. An exit Interview and discussion of observations were conducted with the licensee.



Notice of Site Visit: A Notice of Site Visit (LIC 9213 was given and must remain posted for 30 days.
Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

A copy of this Report was reviewed, and Appeal Rights were also provided to Licensee, Teresa Mendoza.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Joselito DelMundoTELEPHONE: (661) 202-3491
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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