<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845873
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:57:00 PM

Document Has Been Signed on 06/15/2023 01:57 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
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:MANDUJANO FAMILY CHILD CAREFACILITY NUMBER:
334845873
ADMINISTRATOR:MANDUJANO,MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 641-6640
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Maria MandujanoTIME COMPLETED:
02:20 PM
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
On date and time listed, Licensing Program Analyst (LPA) Samuel Lopez arrived at the facility to conduct a required/annual inspection as part of a compliance review. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed:
Normal days and hours of operation are: Monday through Friday, 7:00am to 5:30pm

OFF-LIMIT AREAS INCLUDE: Two total bedrooms (Master included), garage, and side yard (which is fenced)

The facility is operating within the licensed capacity and appropriate ratios (9 children, Licensee, and Assistant)


· An infant was observed sleeping inside of a stroller, in the Master Bedroom with the door closed. This bedroom is labeled as "off limits"
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· This home is not equipped with a fireplace
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Weapons are not present per licensee. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· This is a single story home
· Verification of control of property on file (lease/rental agreement)
· Property Owner/Landlord Consent (LIC 9149)/Notification (LIC 9151) on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training was completed on 7/27/2022
· Pediatric CPR and First Aid Card expire on 6/2024
· Health & Safety Certificate - completed on 4/28/2007 (needs updating) - should have been completed in Sep 2022 - Licensee stated that course was not completed
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873
VISIT DATE: 06/15/2023
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
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster NOT on file
· Documentation of fire and disaster drills is NOT on file
· Children’s records are NOT complete
· Employee’s records are complete (Previously Reviewed)
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

· Resident and/or staff records reviewed on 6/15/2023 indicate that all adults who require caregiver background checks have received all required clearances or exemptions.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov

- LPA discussed the safe sleep regulations with licensee Maria Mandujano 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 Maria Mandujano 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 PIN 22-02-CCP. 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

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873
VISIT DATE: 06/15/2023
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
- Licensee Maria Mandujano 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.

- Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at:


https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

Multiple Civil Penalties have been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.

LPA Samuel Lopez informed licensee Maria Mandujano that this report dated June 15, 2023 document(s) (2) 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.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873
VISIT DATE: 06/15/2023
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
Also, LPA Samuel Lopez informed the licensee Maria Mandujano to provide a copy of this licensing report dated June 15, 2023 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.

The LICENSEE, Maria Mandujano, confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

Exit interview conducted and report was reviewed with the licensee Maria Mandujano.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Samuel Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(i)
Infant Safe Sleep
If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. In conducting the physical inspection, Licensee informed LPA that a child was sleeping in an off limit area (master bedroom). The child was sleeping inside of a stroller. The child woke up and Licensee was reminded of Safe Sleep regulations. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
1
2
3
4
Licensee removed the child upon LPA addressing the issue. Licensee agrees to read Safe Sleep regulations previously provided (7/19/2022) and submit a statement regarding her understanding of the cited section. Also to include plan on how she will maintain compliance. Plan and Statement to be submitted to the Riverside Child Care Regional Office by 6/16/2023.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA Lopez observed that the Master Bedroom door was closed and inside was a sleeping infant, inside of a stroller. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
1
2
3
4
Licensee removed the child upon LPA addressing the issue. Licensee agrees to read Safe Sleep regulations previously provided (7/19/2022) and submit a statement regarding her understanding of the cited section. Also to include plan on how she will maintain compliance. Plan and Statement to be submitted to the Riverside Child Care Regional Office by 6/16/2023.
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing the fire drill log, the last drill was conducted on 7/22/2021. This date was taken from the previous annual inspection due to the log not being available for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to conduct a fire/disaster drill, log it, and submit a copy of the log to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022. A civil penalty is being assessed in the amount of $250.00
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. The licensee did not have documentation available for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to conduct a fire/disaster drill, log it, and submit a copy of the log to the Riverside Child Care Regional Office by 6/30/2023.

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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above. Previously, the licensee had submitted a falsified certificate (Health and safety). Licensee submitted information that she had registered to a course however, never completed the course. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to enroll in a Preventative Health and Safety course, complete it, and submit proof of completion to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022. A civil penalty is being assessed in the amount of $250.00
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed a child sleeping inside of the Master Bedroom, which was labeled as "off limits" by the licensee on the LIC 999 facility sketch. This information was not provided/updated to the Department. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to submit an updated facility sketch showing that the room is now accessible to children in care or a written statement regarding how she is to follow and remain in compliance with the cited regulation. Sketch or statement to be submitted to the Riverside Child Care Regional Office by 6/30/2023.
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing children files, child #8 did not have a signed LIC 995A (parent's rights form) on file for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to obtain a signed copy of the LIC 995A form and submit a copy to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022. A civil penalty is being assessed in the amount of $250.00
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing children files, Child #3 and Child #6, did not have an LIC 700 and/or LIC 627 available for review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to obtain copies of signed LIC 700 and LIC 627 forms and submit copies to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022 and 2/22/2023. A civil penalty is being assessed in the amount of $250.00
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. The roster that was reviewed had several names of children missing and/or information not updated as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to update the facility roster and submit a copy to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022 and 2/22/2023. A civil penalty is being assessed in the amount of $250.00
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. The licensee did not have proof of documenting every 15 minute check for Child #8. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to create an Infant Sleep log and submit a copy with entries, to the Riverside Child Care Regional Office by 6/30/2023.
Please note that this is a repeat violation/citation from previous inspection on 7/19/2022. A civil penalty is being assessed in the amount of $250.00
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 06/15/2023 01:57 PM - It Cannot Be Edited


Created By: Samuel Lopez On 06/15/2023 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MANDUJANO FAMILY CHILD CARE
FACILITY NUMBER: 334845873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595(c)

A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. In reviewing children records, LPA did not observe the required LIC 9224 forms in the children files (Child #4, #5, #7, & #8). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
Licensee agrees to provide parents/legal guardians with copies of all Type A (LIC 809-D) reports issues from 7/19/2022 until current and as proof, have them sign an LIC 9224 form. Copies of signed LIC 9224 forms are to be submitted to the Riverside Child Care Regional Office by 6/30/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Aaron Ross
LICENSING EVALUATOR NAME:Samuel Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
Page: 11 of 11