434405374-5-4-2023-07-CC-DVIA-CRHPZ2-20230504114448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434405374
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:45:18 AM

Document Has Been Signed on 05/04/2023 11:45 AM - 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MEJIA, YOLANDA		FACILITY NUMBER:	434405374
ADMINISTRATOR:	MEJIA, YOLANDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 320-2502
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY:	14	CENSUS: 5	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Yolanda Mejia		TIME COMPLETED:	11:55 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) Deanna Villagrana met with licensee for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's husband and five day care children including two infants. Two of the children are licensee's grandchildren. Licensee's daughter Marisela Mejia arrived a short time later. Days and hours of operation are Monday to Friday, 5:00am to 9:00pm. The adults that reside in the home are licensee and her husband. A review of staff records on 05/02/2023 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee's daughter Marisela Mejia is not associated to the facility. Licensee Yolanda Mejia 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. LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a barricaded fireplace in the home. LPA observed an infant in a car seat. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher a working combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: one bedroom and one bathroom. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off area to the back of the home, detached garage and a portion of the driveway to the left of the home that is fenced off to

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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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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: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)(2)

This requirement is not met as evidenced by: Request a transfer of a criminal record clearance as specified in Section 102370(j)
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Licensee's daughter Marisela Mejia is not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Licensee's daughter will complete LIC9182 and submit along with a copy of her ID to CCLD by POC date. She understands she may not help in the day care until she is associated.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
	VISIT DATE: 05/04/2023

NARRATIVE

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children. LPA observed one dog in the home and licensee states it is vaccinated. LPA observed licensee and her husband have a current CPR and First Aid certification expiring 07/03/2024. Licensee and her husband have not completed Mandated Reporter training.

LPA did not observe a current roster of the children. Licensee stated she is not logging fire and disaster drill's but does complete them. LPA reviewed six children's files. Child 7 does not have a file, only immunization records. Child 1 and 3 are missing immunization records. Child 1 and 2 are missing LIC9227. Licensee states she does not have a Safe Sleep log for infants in care. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee and her husband have immunization records on file.

Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Yolanda Mejia 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 Yolanda Mejia 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.

LPA discussed Zero Tolerance related regulations with licensee Yolanda Mejia and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
	VISIT DATE: 05/04/2023

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 tools, please send them by email 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/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the licensee's daughter Marisela Mejia.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Yolanda Mejia that this report dated 05/04/2023 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.

Also, LPA Deanna Villagrana informed the licensee Yolanda Mejia to provide a copy of this licensing report dated 05/04/2023 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.

A notice of site visit was given and must remain posted for 30 days.

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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102423(a)(2)

Personal Rights

(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. 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 an infant in a car seat which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee removed infant during visit. Deficiency cleared today.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

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 interview, the licensee did not comply with the section cited above. Licensee stated she is not logging fire and disaster drill's but does complete them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will complete a fire and disaster drill and submit and updated log to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee and her husband have not completed Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee and her husband will submit a current Mandated Reporter certificate to CCLD by POC date. Training can be found at www.mandatedreporterca.com.

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. 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. Child 1 and 3 are missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit immunizations for child 1 and 3 to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 interview and record review, the licensee did not comply with the section cited above. Child 7 does not have a file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC700 for child 7 to CCLD by POC date.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. 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. Child 7 does not have a file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC627 for child 7 to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

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 interview and record review, the licensee did not comply with the section cited above. LPA did not observe a current roster of the children which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit a current roster to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

Page: 9 of 12

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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). 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. Child 7 does not have a file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC995 to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

Page: 10 of 12

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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. 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. Child 7 does not have a file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC282 for child 7 to CCLD by POC date.

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. 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. Child 1 and 2 are missing LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC9227 for child 1 and 2 to CCLD by POC date.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2023 11:45 AM - 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEJIA, YOLANDA	FACILITY NUMBER: 434405374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee states she does not have a Safe Sleep log for infants in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee will read Safe Sleep regulations and begin to keep a Safe Sleep log for all infants in care.

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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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