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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011327
Report Date: 07/19/2019
Date Signed: 07/19/2019 12:08:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MENDOZA FAMILY CHILD CAREFACILITY NUMBER:
198011327
ADMINISTRATOR:MENDOZA, IRMA & MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 221-2895
CITY:LOS ANGELESSTATE: CAZIP CODE:
90031
CAPACITY:10CENSUS: 10DATE:
07/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Irma MendozaTIME COMPLETED:
12:22 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lissete Gonzalez conducted an unannounced Annual/Random inspection on 7/19/2019. LPA met with Licensees, Martha Mendoza and Irma Mendoza. Also present in the home was Liliana Mendoza. Licensee, Irma Mendoza, guided the analyst on a tour of the facility inside and outside. Family members residing in the home include four adults (criminal record clearances on file) and one minor.
There were 10 children present.

This is a one-story home which consists of 2 bedrooms, 1 bathroom, kitchen, living room, front yard (fenced), 3 storage rooms in the back yard, and 1 laundry room in the back yard. The children use the living room, one bathroom, one bedroom, the kitchen, and the front yard. The front yard is used for outside play. Off limit areas include one bedroom and the back yard which includes the storage rooms and laundry room. The hours of operation are from 7:00 a.m. to 6:00 p.m. from Monday to Friday.

Areas accessible to children were inspected for cleanliness and proper ventilation and heating. LPA observed the kitchen to be clean and orderly. Knives are stored in a kitchen drawer that does not have a safety latch and are accessible to the children in care. Licensee, Martha Mendoza, immediately removed the knives and stored them in a high cabinet making them inaccessible to the children in care. Cleaning compounds are stored in cabinet with a latch located under the kitchen sink.

There is a working telephone available at the facility. LPA observed the living room to be clean and free of debris. LPA inspected the bathroom used by the children. LPA observed the bathroom to be clean, operational, and sanitary. There is a safety latch in the cabinet located under the bathroom sink where cleaning compounds are stored. LPA observed unused and uncovered electrical outlets in the living room and bathroom. LPA inspected the bedroom used by the children. The bedroom was observed to be clean.

REPORT CONTINUES ON NEXT PAGE: 1 OF 3
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 198011327
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2019
Section Cited
CCR
102421
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Child's Records
This requirement was not met as evidenced by: C5 did not have an immunization record; C7 did not have an immunization record of Parent's Rights Notification form; C10 did not have a file.. This poses a potential risk to the health and safety of teh children in care.
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Per Licensee, will email proof of immunization records and missing children's forms to LPA.
Type B
08/02/2019
Section Cited
HSC
1597.622
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Employee and Volunteer Immunization
This requirement was not met as evidenced by: Licensee, Martha Mendoza did not have proof of immunizations. S1 did not have proof of immunizations. This poses a potential risk to the health and safety of the children in care.
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Per Licensee, will email proof of immunization records for the staff.
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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: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 198011327
VISIT DATE: 07/19/2019
NARRATIVE
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The front yard was inspected. LPA observed age appropriate toys, play equipment, and shade is available. LPA inspected the off-limits storage rooms and laundry rooms. LPA observed a gate with a latch that prevents access to the back yard from the front yard.

Per Licensee, Martha Mendoza, there are no weapons, firearms, bodies of water, or poisons on the premises. The smoke detector was tested and is in operable condition. Licensee, Martha Mendoza, stated they currently do not have a carbon monoxide detector. The fire extinguisher (2A 10BC) is in operable condition. The fire extinguisher was last serviced on 03/26/2019. A disaster drill log is available with the last drill conducted documented on 06/2019. In addition, a complete First Aid Kit was observed.

The children's roster was reviewed and is current. There are currently 10 children enrolled. Children’s records were reviewed to ensure that each child has an immunization record and a record of the Notification of Parent's Rights form. Upon review of children's files, LPA observed C5 did not have an immunization record; C7 did not have an immunization record of Parent's Rights Notification form; C10 did not have a file. Staff records were reviewed. Licensees, Irma Mendoza and Martha Mendoza have current Pediatric CPR/First Aid Certifications on file with an expiration date of 4/28/2020. Licensees, Irma Mendoza , Martha Mendoza completed the Mandated Reporter training on 03/09/2018. Licensee, Martha Mendoza, did not have proof of immunizations. Staff #1 did not have proof of immunizations.

The following was discussed:
Individuals who are 18 years of age or older living in the home must be finger print cleared prior to licensure.
Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate
$100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a
maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an
individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182
Criminal Background Clearance Transfer Request may be used. No smoking, No infant walkers, No Johnny
jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in
the facility. Effective January 1, 2010, licensees of family child care homes are required to ensure that at
least one staff member with current training in pediatric first aid and pediatric CPR is on site at all times when
children are present.

REPORT CONTINUES ON THE NEXT PAGE: 2 OF 3
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 198011327
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2019
Section Cited
CCR
102417(g)
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Operation of a Family Child Care Home
The home shall be free from defects or conditions which might endanger a child. This requirement was not met as evidenced by: LPA observed knives stored in a kitchen drawer without a latch. This poses a potential risk to the health and safety of children in care.
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 Licensee immediately removed the knives and placed them in a high kitchen cabinet. Per Licensee, a latch will be installed in the drawer and a photograph will be sent to LPA.
Type B
07/19/2019
Section Cited
HSC
1596.954
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Carbon monoxide detectors required; inspection
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The Department shall
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Per Licensee, a carbon monoxide will be purchased today. Licensee will submit a photograph of the carbon monoxide detector and receipt as proof to LPA.
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 account for the presence of these detectors during inspections. This requirement was not met as evidenced by: Licensee did not have a carbon monoxide detector in the home. This poses a potential risk to the health and safety of children in care.
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Type B
07/19/2019
Section Cited
CCR
102417(g)
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Operation of a Family Child Care Home
The home shall be free from defects or conditions which might endanger a child.
This requirement was not met as evidence by: Two separate unused electrical outlets were uncovered in the bathroom and living room. This poses a potential risk to the health and safety of children inc are.
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Per Licensee, electrical outlet covers will be placed on all electrical outlets located in areas used by the children. Photographs will be submitted to LPA as proof.
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: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 198011327
VISIT DATE: 07/19/2019
NARRATIVE
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CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED,
Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/ death
reporting, criminal record transfer requirements, criminal record and child abuse clearances were also
discussed during this visit.

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

LPA advised the licensee how to access forms, regulations and quarterly updates on the Child Care Licensing
website at: www.ccld.ca.gov. Safe Sleep and Never Shake a Baby practices were discussed with Licensee.

A copy of the LIC 9213 was given to licensee—Notice of Site Visit. The Notice of Site Visit (LIC 9213) – must
remain posted for 30 days during the hours of operation after each site visit by a licensing representative.
Failure to maintain posting as required will result in a civil penalty of $100.00.

Based on this information, the following deficiencies listed on the attached LIC 809d are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Exit interview was conducted with Licensee, Irma Mendoza. The Licensee was provided a copy of the appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.

*END OF REPORT PAGE: 3 OF 3
SUPERVISOR'S NAME: Adriana HernandezTELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Lissete GonzalezTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5