<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019051
Report Date: 04/10/2023
Date Signed: 04/10/2023 09:58:37 AM

Document Has Been Signed on 04/10/2023 09:58 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MENDOZA C.D.C., RM. P9FACILITY NUMBER:
198019051
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:851 S. HAMILTON BLVD.TELEPHONE:
(909) 397-4438
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 32TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jennifer Perez TIME COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/10/2023, at 8:50 PM, Licensing Program Analyst (LPA) Judy Mora conducted an unannounced case management inspection for an Action Level Exceedance (ALE) detected in a water fixture in the facility. LPA met with Teacher, Jennifer Perez, during the beginning of the visit, Child Development Facilities Licensing Planner, Kym Allen took over the inspection. Also present in the facility were 04 day care children and one additional teacher/staff. Facility was within ratio & capacity.

Analyst reviewed new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with program facilitator during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

Facility provided facility sketch and required forms LIC 9276, LIC999 and LIC 9275 to LPA on 04/10/2023. On 03/22/2023, the Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 03/16/2023. Faucets and drinking fountain reported with 5.5 ppb or greater lead exceedance levels were as follows:

• Sink Faucet Fixture H in Room K9 (6.7 UG/L) – Faucet was replaced and re-tested passing the test. Pictures were taken

At approximately 9:00 AM, LPA observed that the sink is not labeled or taped off. Facilities Planner indicated that the sink is only used for hand washing and not drinking water. Water pitchers and disposable cups are used for drinking water. The use of the faucets was terminated when the facility was informed by the analyst that it was exceeding acceptable levels. The faucet in the classroom has been replaced and re-tested. The facility has not received the results as of this date.

*REPORT CONTINUES ON NEXT PAGE
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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 3
Document Has Been Signed on 04/10/2023 09:58 AM - It Cannot Be Edited


Created By: Judy Mora On 04/10/2023 at 09:26 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: MENDOZA C.D.C., RM. P9
FACILITY NUMBER: 198019051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
101700.3(b)(1)

1
2
3
4
5
6
7
California Lead Action Level at Child Care Centers. (b) Testing results with...readings of 0.5 ppb or greater.., before comparing to the Action Level. (1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met
1
2
3
4
5
6
7
Facilities Planner stated the fixture was replaced and they did the retesting. They are currently waiting for the results. LPA will be sent the results as soon as they are received.
8
9
10
11
12
13
14
as evidenced by Based on record review, the licensee did not comply with the directive above, as one outlet tested with an Action Level Exceedance (ALE). This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Claudia Guangorena
LICENSING EVALUATOR NAME:Judy Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MENDOZA C.D.C., RM. P9
FACILITY NUMBER: 198019051
VISIT DATE: 04/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Grant funding will be available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information,
including additional resources please visit
https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information

See LIC809D for Type B deficiency cited in accordance with California Code od Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A copy of PIN 21-21-CCP and appeal rights were provided to facility today.

A notice of site visit was also provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Kym Allen.


*END OF REPORT
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3