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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376627831
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:44:14 PM

Document Has Been Signed on 11/16/2023 12:44 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:MEDINA, MARY FAMILY CHILD CAREFACILITY NUMBER:
376627831
ADMINISTRATOR:MARY MEDINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(619) 251-6067
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
11/16/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mary Medina TIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/16/23 at 9:30 am Licensing Program Analyst (LPA) Gerald Poindexter conducted an unannounced three-year inspection. Upon arrival, LPA met with licensee Mary Medina. Also, in the home was Lionel Medina, licensee's helper/husband. Present in the home were five (5) day care children, one of whom were under 24 months. Licensee states they typically arrive at approximately 7:00 am. The licensee was provided with the Inspection Checklist (LIC 126). The two-bedroom, one-bath, one-story home was toured and inspected to ensure an environment safe for the care and supervision of children.

The licensee has provided adequate space for the children to eat, sleep and play within the home. Areas used for child care include the living room and covered patio and bathroom. Off limits areas have been made inaccessible with the use of safety gates. There are no stairs in the home.

The home has a fully-fenced, back patio play area available for outdoor activities. No hazards were noted. Parents also drop off at the back patio door. Outdoor play area has age-appropriate play equipment in good condition. The licensee understands that visual supervision is always required during outdoor activities. No body of water was observed during time of inspection.

There is a fully charged fire extinguisher, smoke and carbon monoxide detector that meet requirements and are operational. There is a fireplace with locked and barricaded doors. Poisons, cleaning compounds, medications and other hazardous items are inaccessible to children via safety gates and high placement. Adequate heating and ventilation are provided and vents are place high near the ceiling. There is a working telephone and email address. Licensee stated there are NO firearms and weapons in the home.

CONTINUED ON PAGE 2

SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: MEDINA, MARY FAMILY CHILD CARE
FACILITY NUMBER: 376627831
VISIT DATE: 11/16/2023
NARRATIVE
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LPA observed all required postings were posted. Children’s records were reviewed and found to be incomplete. Staff records were reviewed. Licensee has the required immunizations per SB792. Licensee’s and helpers Pediatric CPR/First Aid are current with an expiration date of 6/17/25. Preventative health practices course was completed, which includes lead poison prevention training. Licensee and helpers/husband, Lionel Medina, Mandated Reporter Training Certificates per AB1207 were not current. LPA advised that they must be renewed every 2 years.

Emergency drills are conducted and documented with the last one being on 8/1/23. Licensee maintains a current roster of the children which LPA obtained during time of inspection. LPA verified that all adults living or working in the home have been fingerprint cleared and associated. LPA reminded Licensee that all unusual incident reports shall be submitted to Licensing office via email at SDIncidentReports@dss.ca.gov or via fax at (619)767-2203. Duty officer number is (619) 767-2248.



The 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.

LPA conducted child care quality management staff interview with the licensee. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Mary Medina of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

CONTINUED ON PAGE 3
SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: MEDINA, MARY FAMILY CHILD CARE
FACILITY NUMBER: 376627831
VISIT DATE: 11/16/2023
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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/.

The licensee Mary Media 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

See LIC809D for deficiencies cited.



Exit interview conducted and report was reviewed with the licensee Mary Medina. During the exit interview, the licensee Mary Medina, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Joelle Redding
LICENSING EVALUATOR NAME: Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2023 12:44 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 11/16/2023 at 11:58 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MEDINA, MARY FAMILY CHILD CARE
FACILITY NUMBER: 376627831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and photo documentation, the licensee did not comply with the section cited above in four of four instances, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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 Licensee removed all toys and blankets from cribs observed by LPA. In the future, licensee says she will adhere to the regulations that prohibit such items.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, LPA observed that completed and signed LIC627 CONSENT FOR EMERGENCY MEDICAL TREATMENT forms were missing in the files of 2 of 8 children enrolled.

POC Due Date: 11/23/2023
Plan of Correction
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Licensee states they will provide completed and signed LIC627 form to LPA Poindexter via email or other delivery method by 11/23/23.
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:Joelle Redding
LICENSING EVALUATOR NAME:Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/16/2023 12:44 PM - It Cannot Be Edited


Created By: Gerald Poindexter On 11/16/2023 at 11:58 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MEDINA, MARY FAMILY CHILD CARE
FACILITY NUMBER: 376627831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee maintained incomplete records for the times of each check for one of two infants in care. License said she checked every 5 minutes, but documentation provided only showed the times she put the child down for nap, not increments of time.
POC Due Date: 12/16/2023
Plan of Correction
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 LPA printed a copy of the CCL Safe Sleep Log for the licensee. LPA advised that sleep times should be documented every 15 minutes, not every 5 minutes. Licensee states she will use the CCL Safe Sleep Log or create one of her own and keep updated as required. Licensee will email an example of proper timekeeping to LPA Poindexter by 12/16/23.
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.
SUPERVISOR'S NAME:Joelle Redding
LICENSING EVALUATOR NAME:Gerald Poindexter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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