274415573-4-21-2020-07-CC-FCJO-BNVRPF-20200421131151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274415573
Report Date: 04/21/2020
Date Signed: 04/21/2020 01:12:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MENDEZ, LETICIA		FACILITY NUMBER:	274415573
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	04/21/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Leticia Mendez		TIME COMPLETED:	09:31 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an announced Case Management Tele Visit to the home today, with the purpose of reactivate the license. LPA contacted Leticia Mendez, Licensee, via WhatsApp. Licensee does not have Skype or FaceTime apps. Days and hours of operation will be Monday thru Saturday from 4:00 AM to 12:00 AM. The adults that reside in the home are the Licensee, her daughter Francis, her son Carlos, and her roommates Leonel and Yamileth. Licensee stated also in her home reside minor children ages 15, and 13 years old. LPA observed there were not children in care during today's Televisit. Licensee's certifications for CPR and First Aid is current and will expire on 6/15/2021. LPA toured the indoor and outdoor areas of the home during today's televisit. The Licensee has a working telephone in the home. Licensee stated that off limit areas indoors are: Four bedrooms, LPA observed there are not stairs in the home. The off limits area outside the home are two storage sheds located in the back yard. LPA observed the home has a back yard and it is fenced. Licensee uses the back yard as playground. LPA observed a fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors and no bodies of water. The Licensee states that she does not have any weapons in the home. Licensee understands that all kind of detergents, cleaning compounds, medications, and other similar items must be stored inaccessible to children. LPA observed the home has a fireplace and a wall heater, both are barricaded Licensee has in file proof of having immunization for pertussis and measles and influenza according with the SB792. A review of staff records on 04/21/2020 indicates that all the adults in the home or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time. ******************************Report dated 04/21/2020 continues in page 2.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2020

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENDEZ, LETICIA	FACILITY NUMBER: 274415573
	VISIT DATE: 04/21/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Report dated 04/21/2020 continues from page 1.

Licensee states that she will transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.

LPA advised the Licensee of the required "mandated reporter" training that all Licensees will be required to complete starting January 1, 2018. Licensee understands the training is mandatory and stated she will take it whenever the training is available in Spanish. LPA referred the Licensee to the training website: www.mandatedreporterca.com for additional information on the online training.
LPA advised applicant of the pending Department regulation update re: safe sleep for infant children. LPA referred the applicant to the Department website: www.ccld.ca.gov

No deficiencies were cited during the televisit. Televisit was conducted with licensee in Spanish.

A NOTICE OF SITE VISIT WAS ISSUED AND ATTACHED TO THIS REPORT, MUST BE POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

Licensee understands that this report will be emailed to her and Licensee shall reply upon receiving confirming she has received the report via email. Licensee understands her license will be reactivated when LPA receives confirmation of licensee receiving the report.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2