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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008304
Report Date: 04/08/2025
Date Signed: 04/08/2025 12:20:09 PM

Document Has Been Signed on 04/08/2025 12:20 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MEDINA FAMILY CHILD CAREFACILITY NUMBER:
198008304
ADMINISTRATOR/
DIRECTOR:		MEDINA, SUSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 793-8597
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
04/08/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Licensee Susana MedinaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 4/8/25 at 10:20am, Licensing Program Analysts (LPA)s Stephanie Li and Mary Silva conducted an unannounced annual inspection to the above facility. A risk assessment was conducted upon entry. LPA’s met with Licensee Susana Medina and Daughter Brenda Medina, who led LPA’s on a tour of the facility. There was 7 children and 6 adult present upon arrival. Per Licensee, there is currently 14 children enrolled. A current children’s roster was available for review. Licensee is Spanish speaking and visit was translated in Spanish by LPA Mary Silva.

This is a one-story house which consists of 3 bedrooms, 2 bathrooms, living room, kitchen, converted garage, enclosed front yard, enclosed side yard, and enclosed back yard. The children use the front bathroom, living room (play area), 1 bedroom (nap room), enclosed side yard (play area) and fenced front yard. Per licensee, areas off limits to children and parents include: 1 bedroom, kitchen, 1 bathroom, garage and back yard. Hours of operation is from Sunday- Saturday 6:00am-11:00pm.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness.

The following was observed and reviewed during this inspection. Cleaning compounds, and medications were observed to be inaccessible to children. Per licensee, there are no poisons kept in the home. The restroom that children use was observed to be safe and sanitary. There is telephone service via landline and cellphone that stays at the facility during operation hours. The home is observed to be clean and orderly with wall ac unit and space heaters. Heater was observed to be barricaded and in assessable. There are toys available for children. Licensee has cots and playpens for napping children. There are first aid supplies available. Page 1 of 3
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Stephanie Li
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 198008304
VISIT DATE: 04/08/2025
NARRATIVE
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LPA’s observed the following required posted documentation in the entryway: Facility License, (LIC) 9148- Earthquake Preparedness form, Publication (PUB) 394- Notification of Parent Rights, and LIC610- Emergency Disaster Plan. Provider is signed up with Pacific Clinics and participating in the Early Head start, Options, and Food program.

At 11:00am, LPA’s observed the required 2A 10BC fire extinguisher last serviced on 08/2024. Smoke and carbon monoxide detectors were tested and are operable. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill was conducted on 2/1/25. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home.
Children are currently using the fenced side yard and front yard for outdoor play. The outdoor play area was observed to be fenced. LPA’s observed the outdoor yard to have appropriate toys and other materials for children to use. LPA’s observed a space between the shaded canopy and wall with broken bricks used as weights for the tarp. LPA’s advised to barricade and restrict access from children. Licensee stated she will place something in front to barricade. The licensee is observed to be operating within the license capacity limitations. LPA’s inquired about water play during the summer. Licensee stated they use kiddie pools and LPA’s advised about water safety certificate requirement and where to obtain the training.

At 11:30 am, children and adults records were reviewed, including emergency information and documented on LIC857. Licensee has completed CPR/First Aid training. LPA’s advised that CPR/First Aid needs to be completed with EMSA approved trainers. LPA’s observed licensee’s spouse who works with the children does not have current mandated reporter certificate. Deficiency is being issued. See page LIC809D.

Licensee stated IMS is not being provided at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Stephanie Li
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 198008304
VISIT DATE: 04/08/2025
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LPA discussed the safe sleep regulations and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/safe-sleep as an additional resource. LPA also informed applicant/licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Megan’s Law - Family Child Care Homes During the exit interview, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov



MyChildCarePlan.org – Centers and Family Child Care Homes Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. Licensee participates in R & R programs, Options- QSLA-UCLA curriculum bridge and options food program.

Based on Licensing staff observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

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

Exit interview conducted and report was reviewed with Licensee Susana Medina.



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NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Stephanie Li
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2025 12:20 PM - It Cannot Be Edited


Created By: Stephanie Li On 04/08/2025 at 12:02 PM
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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MEDINA FAMILY CHILD CARE
FACILITY NUMBER: 198008304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025

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
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Based on observation and record review, the licensee did not comply with the section cited above in one adult working with children does not have current mandated reporter certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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Per licensee, she will have her dad complete training and send the certificate to LPA S Li via email by 4/15/2025.
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.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Stephanie Li
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
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