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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845127
Report Date: 11/13/2019
Date Signed: 11/14/2019 10:56:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:MENDOZA FAMILY DAY CAREFACILITY NUMBER:
334845127
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
11/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Maria Mendoza TIME COMPLETED:
10:15 AM
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"THIS REPORT IS ELECTRONIC VERSION/HAND WRITTEN COPY WAS PROVIDED TO LICENSEE ON DATE LISTED UNABLE TO PRINT DUE TO COMPUTER PERFORMING CONSISTENCY CHECK." See hand written copy for original signature.

Licensing Program Analyst (LPA) Timeka Reed arrived to the facility for the purposes of conducting a case management visit. The Licensee has applied to increase the capacity to that of a large Family Child Care home. LPA toured the home and reviewed records. Licensee has a qualified assistant. There were no deficiencies observed at the time of the visit. Qualified assistant needs to complete mandator reported training. Once training is complete, Licensee must send proof to Licensing to be approved for a capacity of 12 or 14 with parent notification within 30 days. Due to technical difficulty at the time of visit. This report is being generated manually. A copy of this report was given and explained to Licensee.
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Timeka ReedTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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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