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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019051
Report Date: 05/27/2025
Date Signed: 05/27/2025 03:12:12 PM

Document Has Been Signed on 05/27/2025 03:12 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:MENDOZA C.D.C., RM. P9FACILITY NUMBER:
198019051
ADMINISTRATOR/
DIRECTOR:		KYM ALLENFACILITY TYPE:
850
ADDRESS:851 S. HAMILTON BLVD.TELEPHONE:
(909) 397-4438
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 8DATE:
05/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 AM
MET WITH:Roxann OrnelasTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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 This is a Case Management For EHS Rm 10.
At 1:00Pm LPA Kamile Martin spoke with teacher 2 in regards to UIR unusual incident report received on 5/22/25. via email. On 5/27/25 LPA KMartin arrived at Mendoza EHS rm 10. To see if child had arrived for the day. A census was conducted and 8 children and two teachers (1 Substitute) are in the classroom. Teacher 2 said children just finished lunch and were a sleeping. Teacher 1 was absent today. She made the report and notified supervisor of the incident.
Upon observation Social Worker arrived to the classroom to follow up on the incident of the child as well. Because children were sleeping Social worker provided her information and will return tomorrow morning for further investigation
Child is two years old and her home language is Spanish. She does respond in English sometimes. Child woke up from nap at 1:55 and LPA KMartin spoke with child briefly, child was still waking up and not coherent. Teacher 2 notified LPA child may be going home soon.
The child;s mother or Aunt picks up the child at 2:00 no later than 2:30.
It was disclosed that child has experienced unusual behavior lately. Child has been observed rubbing her chest area through out the day and often soothes her body to sleep by rubbing her chest. It was also observed child's behavior has changed recently she has been observed being mean to friends and hitting peers. Since the child has disclosed information about abuse the father no longer picks the child up from school.
Home visits were conducted in March both teachers were present for the visit and both parents were home for the visit as well.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2025
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: MENDOZA C.D.C., RM. P9
FACILITY NUMBER: 198019051
VISIT DATE: 05/27/2025
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While writing report Mental Health Specialist from Pomona Unified arrived to conduct an investigation with the child.
LPA Kamile spoke with child briefly when she woke up after nap ad child was not responsive to conversation during this time.
When Mental Health specialist spoke with child she was open and responding and providing information in Spanish but not pertinent information in regards to her injury.
Specialist will return tomorrow morning.
At 2:38 A male adult arrived to pick up child but he was not on the emergency list to pick up child. Teacher 2 called mom to verify unauthorized male to pick up. He was not authorized to pick up child. mom said its her sisters husband. Teacher 2 said child can not go home with this male mother needs to have someone authorized to pick up child. And the procedures were explained to the mom over the phone. Which is the child needs to be picked up before 3:00 if no one picks up supervisor will arrive and sit with child and police will be called.

LPA Kamile Martin has contact information for Social worker and Mental Health specialist and will follow up to ensure the safety and well being of the children in care.

A notice of site visit was given to Roxanne Ornelas.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
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: MENDOZA C.D.C., RM. P9
FACILITY NUMBER: 198019051
VISIT DATE: 05/27/2025
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 Pomona Unified Mental Health Specialist arrived to interview the child after nap time.
She was unsuccessful. She stated she will arrive tomorrow morning as well to speak with child. She provided her information to LPA KAmile Martin.

Adult male arrived to pick up child he was not authorized on the emergency contact he said he was the child's uncle. Teacher 2 called mom , mom states he is the husband of her sister. Per policy teacher 2 stated the policy suggested parent picks up or someone authorized to pick up. Aunt arrived at 3:07 pm Aunt states mom just started working last week and she can add uncle to emergency ccontacts tomorrow morning.
Further investigation will be conducted LPA will keep in contact with Social worker and Mental health specialist.
A notice of visit was given to teacher 2 Roxanne Ornales.

NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
LIC809 (FAS) - (06/04)
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