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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413520
Report Date: 11/20/2023
Date Signed: 12/08/2023 02:26:49 PM


Document Has Been Signed on 12/08/2023 02:26 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:MENDOZA, CELINAFACILITY NUMBER:
434413520
ADMINISTRATOR:MENDOZA, CELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 425-1729
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 2DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cenlina MendozaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sheena Chin conducted an unannounced Case Management inspection at the facility today and met with Celina Mendoza. The purpose of today’s inspection is to review the amended 10/27/2023 report with the licensee and follow up on plan of correction.

Plan of Corrections Follow-UP
The licensee had 3 deficiencies during the inspection on 10/27/2023: 1: the licensee did not have fire drill at least every 6 months, correction due date 11/03/2023; 2: the licensee did not have the mandated reporter training certificate, due date: 11/10/2023; and 3: the licensee did not have each parent sign the affidavit regarding liability insurance as the licensee did not purchase the liability insurance, correction due date: 11/03/2023. During today’s inspection, the records showed that the facility had a fire drill on 11/10/2023. However, the licensee was not able to provide proofs of signed affidavit form nor the mandated reporter training certificate.The licensee hasn't contacted the licensing department since 10/27/2023 regarding deficiency corrections. The licensee said that she was too busy to correct the three deficiencies by due dates.
Observation & records review
The facility has 2 children in care during the inspection. LPA reviewed the children’s records and found that the facility did not maintain the vaccination records for the C1, 5 years old in care today.

Deficiency
Regulatory violation was observed during the inspection. Citations were issued.

Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, Celina Mendoza.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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 2


Document Has Been Signed on 12/08/2023 02:26 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: MENDOZA, CELINA
FACILITY NUMBER: 434413520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2023
Section Cited
HSC
1596.8662(b)(1)

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider,... shall complete the mandated reporter training ... and shall complete renewal mandated reporter training every two years...
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The licensee will submit the mandated reporter training certificate.
Type B
12/04/2023
Section Cited
CCR
102417(m)(3)

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(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.
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The licensee will send the copies of the affidavit regarding liability insurance
Type B
12/04/2023
Section Cited
CCR102418(g)

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(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
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The licensee will send a copy of C1 chid's immunization records.

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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: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2