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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845790
Report Date: 09/27/2021
Date Signed: 09/27/2021 10:56:31 AM

Document Has Been Signed on 09/27/2021 10:56 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:MENDIOLA FAMILY CHILD CAREFACILITY NUMBER:
334845790
ADMINISTRATOR:MYRNA MENDIOLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(760) 449-8294
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
09/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Myrna MendiolaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Blanca Ruiz-Silva conducted and inspection at the facility to follow up on an incident learned during an investigation of complaint 09-CC-20210730135525. Present during this inspection were licensee and licensee’s assistant, Cindy Zuniga. LPA observed 12 children playing outside in the backyard and later engaged in age appropriate activities in the daycare room under the supervision of licensee and licensee’s assistant. During this inspection licensee was reminded of best practices related to social and physical distancing.

LPA spoke with licensee, Ms. Myrna Mendiola and discuss the violation identify through the investigation previously mentioned. During today's inspection plans of corrections associated with deficiencies were addressed. Based on information obtained from facility records reviewed, witnesses, and licensee statements, the following violations have been identified: Reporting Requirements and Personnel Records.

On August 5, 2021, LPA Ruiz arrived to the facility to conduct and inspection, when LPA requested to review records from Staff#1 and Staff#2. Licensee stated that no records were available for review since both staff are no longer working at the facility since last year. It was also learned that on or about 12/2020 the licensee failed to report an unusual incident that occurred at the facility that jeopardized the health and safety of the children in care.

Licensee was remained to be in close communication with Community Care Licensing (CCL) to address any questions, concerns and/or to verify compliance. Lastly, licensee was advised to contact the Duty Officer available Monday-Friday 8:00 a.m. to 5:00 p.m. to obtain clarification if needed at (951)782-4200. See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.


An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to facility staff. The Notice of Site Visit and Type a Deficiencies from today's visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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Document Has Been Signed on 09/27/2021 10:56 AM - It Cannot Be Edited


Created By: Blanca Ruiz-Silva On 09/23/2021 at 07:42 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: MENDIOLA FAMILY CHILD CARE
FACILITY NUMBER: 334845790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
102416.1(c)

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All personnel records shall be kept for at least three years following termination of employment/volunteer work. This requirement was not meet as evidence by:
Per licensee's own admission, staff records were not available for review during LPA’s inspection on 08/05/21.
This poses a potential Health, Safety or Personal Rights risk to the children in care.
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Licensee agrees to submit a written statement regarding her understanding of personnel records in addition to provide proof of a prepare packet download of all required forms. Licensee understands that all forms must be completed by prospective staff before he/she starts working at the facility.
Type B
10/01/2021
Section Cited
CCR
102416.2(d)(1)

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Reporting Requirements -
(1) Health and Safety Code Section 1597.467(b)(1) provides in part:" A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home of…the…events."

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Licensee agrees to submit a written statement regarding her understanding of Reporting Requirements and the LIC 624B regarding the incident in question. Both are to be submitted to the Riverside Child Care Regional Office by 10/01/2021.

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This requirement was not being met as evidenced by: Licensee’s fail to report verbally and in writing, via the Unusual Incident Report form (LIC624B), an incident involving a staff being absent from the facility due to health related issues. This poses a potential Health, Safety or Personal Rights risk to the children in care.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


LIC809 (FAS) - (06/04)
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