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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504126
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:41:31 PM


Document Has Been Signed on 03/02/2023 04:41 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MENDOZA, ELSA & MENDOZA, JORGEFACILITY NUMBER:
380504126
ADMINISTRATOR:MENDOZA, ELSA & JORGEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 282-3793
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 4DATE:
03/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jorge Mendoza, Elsa MendozaTIME COMPLETED:
04:50 PM
NARRATIVE
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On 3/2/2023 at 2:00PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Jorge Mendoza and Elsa Mendoza. Purpose of the inspection was explained and was for an Unannounced; Annual Random inspection. Present in facility were both licensees caring for three children (1 infant age, 2 preschool age). A forth child, school age child, arrived during inspection. Adults present have criminal record clearances on file. Licensee’s home is a 2 bedroom, 1 bathroom, 1 level apartment. Days and hours of operation are Monday- Friday: 7:00am- 6:00pm. Day care areas are: Living Room (Playroom), Bedroom #1 (Napping only), and Bathroom #1 Off Limit areas are: Bedroom #2 (Office). LPA inspected home with licensee for health and safety hazards.

At 2:10PM., the following was observed: Facility was clean, orderly, with age-appropriate playthings and materials available for the children. Floors and ground surfaces were clear of obstructions or potential hazards. Storage is available of children’s belongings. Accessible furniture, toys and books inspected were in good repair. Licensee has table and chairs for meals and activities. For napping services, LPA observed an infant playpen (with tight-fitting sheets) and several cots in playroom. Bathroom #1 has adequate supplies for hand washing. Fixtures tested were in operating condition. Off-limit areas have been made inaccessible to childen. Facility was the proper temperature, with ventilation, and lighting. Home had functioning telephone; smoke detector, carbon monoxide detector; and fire extinguisher, 2A:10BC, fully charged.

Home does not have any pools, fish ponds, jacuzzis, or bodies of water.
(REFER TO 809C, FOR CONT)
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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Document Has Been Signed on 03/02/2023 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MENDOZA, ELSA & MENDOZA, JORGE
FACILITY NUMBER: 380504126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 3:00PM., Based on record review and interview, LPA confirmed licensee is missing immunization record and file for infant-age child, C1, in care. This poses a potential health and safety risk to children in care.
POC Due Date: 03/16/2023
Plan of Correction
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Licensee will obtain missing immunization records and required forms for day-care child, (C1) by the due date: 3/16/2023. Proof of correction will be submitted to the department via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MENDOZA, ELSA & MENDOZA, JORGE
FACILITY NUMBER: 380504126
VISIT DATE: 03/02/2023
NARRATIVE
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(Page 2)
At 2:40PM, LPA reviewed facility and children’s records. Children’s files were reviewed and included the: Identification of Emergency Information (LIC700); Notice of Parent's Rights (LIC995); Health History (LIC702); and Consent for Medical Treatment (LIC627).

At 3:00PM., Based on record review and interview, LPA confirmed licensee is missing immunization record and file for infant-age child, C1, in care.

LPA reminded licensee to document infant napping conditions every 15 minutes. Advisory Note: Technical Violation (LIC9102TV) was issued.



At 3:05PM., Based on record review, LPA confirmed licensee missing 'Individual Infant Sleeping Plan' for infant in care. Advisory Note: Technical Assistance (LIC9102TA) was issued.

Licensee’s 'Mandated Reporter Training' Certification (AB1207) was current: expiring 3/17/2024.
Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid certification was current, expiring: 6/2024.

Licensee is conduct, and document emergency disaster drills once every 6 months, with last one done on: 1/31/2023. LPA reminded licensee to log every emergency disaster drills conducted.

Required posting are entry way: including Childcare License, Notification of Parent’s Rights (PUB379), and Emergency Disaster Plan (LIC610A). LPA reminded licensee to have posting visible for families.

Per licensee, isolation of ill children is in playroom.

Per licensee, facility provides snack, foods services for children in care. LPA reminded licensee to ensure all children’s meal containers brought by families should be labeled. Per licensee, home does not have firearms.

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.


(REFER TO 809C, FOR CONT.)
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MENDOZA, ELSA & MENDOZA, JORGE
FACILITY NUMBER: 380504126
VISIT DATE: 03/02/2023
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(Page 3)
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.

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, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. Exit interview, appeal rights and and report was discussed with Licensee Jorge Mendoza, and signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC809 (FAS) - (06/04)
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