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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700147
Report Date: 10/14/2021
Date Signed: 10/14/2021 05:23:41 PM

Document Has Been Signed on 10/14/2021 05:23 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MENDOZA FAMILY CHILD CAREFACILITY NUMBER:
367700147
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 5DATE:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Licensee, Yamileth Mendoza TIME COMPLETED:
05:25 PM
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On October 14, 2021 at 03:20pm Licensing Program Analyst (LPA) Kendal Zirbes met with Licensee Yamileth Mendoza to conduct an unannounced case management inspection. The purpose of the case management was to follow up on a self-reported unusual incident report (UIR) submitted to the Department on September 29, 2021 via telephone. The unusual incident report was regarding a supervision incident involving child 1 (C1) and child 2 (C2) that occurred on September 29, 2021. Upon arrival, LPA observed five children (three infants and two toddlers) and one staff member (Licensee) providing care.

During this inspection LPA conducted one interview and completed a file review. In addition, LPA completed a safety inspection of the facility at approximately 03:25pm. In addition, during the inspection, LPA obtained copies of documentation related to the case management incident.

Due to the need to gather additional information, the case management will require further investigation.

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

An exit interview was conducted, during which this report and the Appeal Rights were discussed with the Licensee, Yamileth Mendoza.


SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Kendal Zirbes
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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