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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 543911006
Report Date: 08/26/2021
Date Signed: 08/26/2021 10:33:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:MONDRAGON, BERENICE FAMILY CHILD CAREFACILITY NUMBER:
543911006
ADMINISTRATOR:MONDRAGON, BERENICEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(559) 318-4378
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:14CENSUS: 1DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Berenice MondragonTIME COMPLETED:
10:45 AM
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On 08/26/21 Licensing Program Analyst's (LPAs) Nancy Her and Jose Penate, conducted an unannounced Annual Required Inspection and was met by Licensee, Berenice Mondragon. Licensee is Spanish Speaking and LPA Jose Penate assisted with interpretation. Days and hours of operation are Monday through Saturday 5:30 am to 5:30 pm.

LPAs toured the home inside and outside and a census was taken. LPA received updated facility sketch. Licensee confirmed that the kitchen, dining room, bathroom, living room, and daycare room, are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of spinning door knob covers. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

The fireplace located in the living room is made inaccessible by a glass door and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Stairs are fenced or barricaded when children under age 5 years old are present. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (559) 318-4378.

There are currently no infants in care. LPA discussed Safe Sleep Regulations with licensee. There shall be one crib or play yard for each infant in care. Cribs and play yards are to be kept free from all loose articles and objects while infants are sleeping, and there shall be no objects hanging above or attached to the crib or play yard. Infants are to not be swaddled while in care. Provider will physically check on sleeping infants every fifteen minutes and document any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants will need to be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan will need to be completed and on file for each infant up to 12 months of age. Infants up to 12 months of age are to be placed on their backs for sleeping.

Continued on 809-C

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: MONDRAGON, BERENICE FAMILY CHILD CARE
FACILITY NUMBER: 543911006
VISIT DATE: 08/26/2021
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Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPAs reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 08/18/20. Licensee’s pediatric CPR/First Aid expires on 06/27/22. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.

All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy HerTELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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