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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418365
Report Date: 07/05/2022
Date Signed: 07/05/2022 11:53:47 AM

Document Has Been Signed on 07/05/2022 11:53 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MENDOZA FAMILY CHILD CAREFACILITY NUMBER:
197418365
ADMINISTRATOR:MENDOZA, MARIANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 368-5366
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:MENDOZA, MARIANGELA- LicenseeTIME COMPLETED:
12:15 PM
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On 07/05/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, Mariangela Mendoza. Also present was Staff #1 (S1). Days and hours of operation are Monday through Friday 7a to 6p.

LPA toured the home inside and outside and a census was taken. LPA observed 9 children in the home. Current facility sketch reviewed and Licensee confirmed that the dining room, drop off/pick up room, restroom located in the hallway, room 1, room 3 and room 4, are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locked doors and child safety gates. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There are 3 working fire extinguishers in the home which were serviced on 5/2022 one located in the kitchen, room 4 and in the hallway area. Multiple smoke detectors located throughout and 2 carbon monoxide detectors located in the dining room and room 4, tested by the licensee. There is adequate heating and ventilation for safety and comfort. There are no stairs in the home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 368-5366.

There are currently 2 infants in care over 12 months. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes as well as any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/05/2022 11:53 AM - It Cannot Be Edited


Created By: Suzette Ornelas On 07/05/2022 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197418365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 staff did not have all the required immunizattions which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Licensee will email proof of TB/MMR to LPA.
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:Lisa Rios
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022


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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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197418365
VISIT DATE: 07/05/2022
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 Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan was discussed and will be kept in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. LPA did not obsereve 15 minute checks for sleeping infants in file. LPA provided licensee with a copy of the safe sleep regulation, a safe sleep brochure, sample safe sleep log, and safe sleep Frequently Asked Questions and explained information to ensure documentation will be maintained. Licensee began creating safe sleep logs immediately and will ensure to maintain documentation readily available.

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. Licensee was reminded to ensure outdoor equipment is dusted off regularly to ensure no bugs are present. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. LPA observed PM 286 to be missing in all children's files, information was provided on how to access the form as well as a physical copy of the form. Licensee’s Mandated Reporter Training has not yet been completed. Licensee will provide proof of completion via email for all staff to LPA. Licensee’s pediatric CPR/First Aid expires on 2024. A review of records indicates that all employees and/or volunteers do not have immunization records on file for influenza, pertussis and measles. Licensee will provide proof of immunization records for S1 via email. 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
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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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: MENDOZA FAMILY CHILD CARE
FACILITY NUMBER: 197418365
VISIT DATE: 07/05/2022
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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, the following deficiencies are being cited:
Type B: 1597.622(c)- Employees or volunteers at family day care home; immunization requirements; records; exemptions
(see next page, 809 D) Licensee was provided a copy of appeal rights.

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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC809 (FAS) - (06/04)
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