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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414727
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:58:31 PM


Document Has Been Signed on 04/21/2022 03:58 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:BARBOZA MENDIOLA, SOFIA ROSAFACILITY NUMBER:
434414727
ADMINISTRATOR:BARBOZA MENDIOLA, SOFIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 653-9040
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:14CENSUS: 10DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Sofia Barboza MendiolaTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Required - 1 Year Inspection. LPA met with Licensee, Sofia Barboza Mendiola, and explained the purpose of today's visit. Also present in the home were licensee's 15-year-old son, licensee's two adult helpers, and 10 daycare children including four (4) infants and six (6) preschool age. LPA toured both indoor and outdoor areas during the inspection. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 6:00 AM- 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states there are two adults residing in the home: herself and her daughter.

Licensee 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 reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on April 18, 2022. LPA observed a fully charged 3A40BC fire extinguisher, glass covered fireplace, and functioning smoke and carbon monoxide detectors. Licensee states that there are no weapons or firearms in the home.

This facility provides Incidental Medical Services – IMS. Licensee states that currently, there are no children on medication. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice 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

Continuation on next pages:

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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 4


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: BARBOZA MENDIOLA, SOFIA ROSA
FACILITY NUMBER: 434414727
VISIT DATE: 04/21/2022
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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: 2 bedrooms, master bedroom, master bathroom, furnace closet, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as table, chairs, couches, and shelves are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via individual water bottles. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (415) 653-9040.

The outdoor licensed areas of the home were inspected and observed to be fenced in. No off limit areas outside the home. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed Licensee 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.

Ten (10) children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical (LIC627), Identification and Emergency Information (LIC700), and Immunization Records. Licensee carries daycare insurance.

LPA reviewed two (2) helper's files. Licensee has Immunization Record showing immunity to measles (MMR), pertussis, and flu. The Licensee has Mandated Reporter Training that expires on August 2, 2022. Licensee's CPR/First-Aid expired on August 19, 2019. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

Continuation on next page:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: BARBOZA MENDIOLA, SOFIA ROSA
FACILITY NUMBER: 434414727
VISIT DATE: 04/21/2022
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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, Sofia Barboza Mendiola.

As a result of today's inspection, deficiency was cited on next page:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/21/2022 03:58 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: BARBOZA MENDIOLA, SOFIA ROSA
FACILITY NUMBER: 434414727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

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
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Based on record review, Licensee's CPR/First Aid expired on August 19, 2019. This poses a potential risk to the health, safety or personal rights of children in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee states she will submit proof of current Pediatric CPR/First Aid by 06/03/22.
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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou MonicoTELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4