380504126-3-18-2022-05-CC-LGOZ-CCMU36-20220318151302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504126
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:13:13 PM

Document Has Been Signed on 03/18/2022 03:13 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MENDOZA, ELSA & MENDOZA, JORGE		FACILITY NUMBER:	380504126
ADMINISTRATOR:	MENDOZA, ELSA & JORGE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 282-3793
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	12	CENSUS: 3	DATE:	03/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jorge Mendoza		TIME COMPLETED:	03:30 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 3/18/2022 at 12:30A.M., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Jorge Mendoza. Purpose of the inspection was explained and is for an unannounced, annual/ random inspection. Present was the licensee caring for 3 children. All children present were preschool age. Licensee’s home is a 2 bedroom, 1 bathroom, 1 level apartment. Hours of Operation are: Monday- Friday: 7:00am- 9:00pm. Day care areas are: Living Room (Playroom), Bedroom #1 (Napping only) and Bathroom #1 Off Limit areas are: Bedroom #2 (Office). LPA inspected entire home with licensee for health and safety hazards. At 12:40A.M., the following was observed: Home was maintained clean and orderly with all age appropriate playthings available for the children. Accessible furniture and items inspected were in good repair. Facility kitchen had a seating area for lunch and snack. Licensee installed padded squares tiles on floor for added safety. Safety barrier has been installed on Playroom windows. For added storage, LPA observed individual cubbies located next to the facility’s kitchen. For napping services, cots and mats were available and located in the playroom. Per licensee, children’s napping blankets are washed weekly. Accessible outlets, open-faced heater and trash bins had been covered. Bathroom #1 was observed clean with adequate supplies. Bathroom fixtures were in proper operating condition. Off-limit areas had been made inaccessible. Cleaning detergents, compounds, wipes, spray bottles and other items, which could pose a danger, are stored under kitchen sink. Facility was the proper temperature with adequate ventilation and lighting. Home had a functioning telephone service, smoke/ carbon monoxide detector combo and fully charged fire extinguisher (3A:40BC), located in kitchen. (REFER TO 809C FOR CONT.)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MENDOZA, ELSA & MENDOZA, JORGE	FACILITY NUMBER: 380504126
	VISIT DATE: 03/18/2022

NARRATIVE

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At 1:10P.M., LPA reviewed facility and children’s records. Children's records were reviewed and included: (LIC627) Consent for Medical Treatment, (LIC995A) Notification of Parent's Rights and Updated Immunization Records. LPA reminded licensee to ensure children's files contain their signed Identification of Emergency Information (LIC 700) form.

At 1:30P.M., Based on record review, LPA confirmed the licensee's certificate in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) had expired. During inspection, Advisory Note: Technical Violation (LIC9102TV) was issued.

Facility is conducting Emergency Disaster Drills every 6 months, with last drill completed, 12/2021. LPA reminded licensee to document each disaster drill conducted at the facility.

LPA reminded licensee to ensure all forms are properly posted in visible location. Required form include the: Facility License, Notification of Parent’s Rights and Emergency Disaster Plan (LIC610A). Children's roster form had been updated.

Per licensee, no children in care requiring IMS Incidental Medical Services at this time. Per licensee, facility provides daily snack for children in care. LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labelled. Per licensee, home does not have any no guns or weapons.

Licensee was reminded that all adults 18 years and over living or working in the home, including employee and volunteers, must obtain criminal 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 Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MENDOZA, ELSA & MENDOZA, JORGE	FACILITY NUMBER: 380504126
	VISIT DATE: 03/18/2022

NARRATIVE

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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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, no deficiency was observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview and report was reviewed with licensee, Jorge Mendoza and her signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must be posted for 30 days.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC809 (FAS) - (06/04)

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