384004738-9-6-2023-05-CC-CQUO-CVEUXP-20230906155839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004738
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:58:44 PM

Document Has Been Signed on 09/06/2023 03:58 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 BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MENDONCA, MAYRA		FACILITY NUMBER:	384004738
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	09/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mayra "May" Mendonca		TIME COMPLETED:	04:15 PM

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 September 6, 2023 at approximately 1:00pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted a scheduled, pre-licensing inspection. LPA met with applicant, Mayra "May" Mendonca, and explained the purpose of the inspection. Present during LPA's visit included applicant's minor child. Applicant submitted an application for a family child care home May 17, 2023 in an alternate location. Applicant relocated to current address. Applicant lives in the multi-level home with their spouse and minor child. Applicant plans to operate Monday through Friday 7:30am to 6:00pm. Applicant plans to care for children ages 6 months to school age. Applicant is aware children living in the home under 10 years old, are counted towards overall capacity. With applicant, LPA inspected the entire home, inside and outside, for health and safety hazards. The home is a multi-level (3 floor) home that consists of 3 bedrooms, 3 bathrooms, living room, dining area, kitchen, deck, backyard and garage. The DAY CARE AREAS located on the ground level is the backyard. Located on the second level are the living room, dining area, kitchen, bathroom #1. Located on the third level is bedroom #1 (napping room) and bathroom #2. The OFF LIMIT AREAS located on the ground level is the garage (pass by only to backyard). Located on the second level is the deck (pass by only to backyard). Located on the third level is bedroom #2 (office), bedroom #3 (master), and bathroom #3 (located in master bedroom). Off limit areas are made inaccessible with child safety door handles. There are multiple stairs in the home that have a child safety gate installed. LPA observed the day care area to be clean and safe. Home is equipped with a fully charged fire extinguisher that was observed to be secured to wall located near stairs. Home is equipped with multiple smoke detectors. During visit, LPA tested a smoke detector that was observed to be working. Applicant will verify smoke detectors are dual carbon monoxide detectors. Day care areas were observed to be equipped with a variety of toys, materials and furniture that were age appropriate. There is a fireplace in the living room that is properly barricaded and made inaccessible. Windows in living room and dining area were observed to have built in stoppers to limit opening size of windows. Applicant is aware window stoppers must be in place if applicant is to open windows in living room and dining area. LPA observed electrical outlets to be made inaccessible with safety covers. Garbage cans were observed to have tight fitting lids. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MENDONCA, MAYRA	FACILITY NUMBER: 384004738
	VISIT DATE: 09/06/2023

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

(Continued, Page 2...)
Kitchen was observed to be clean and safe. Cabinets and drawers were also observed to have child safety locks installed. Knives and sharp objects are made inaccessible. Bathrooms were observed to be in proper working condition. LPA observed drawers and cabinets to have child safety locks installed. Bathroom is equipped with age appropriate toileting equipment and sanitation products.

The backyard area is entirely enclosed and fenced. LPA observed backyard to have a variety of toys and equipment that were age appropriate. LPA did not observe any pools, spas or bodies of water on site.

Applicant was reminded baby walkers, bouncers, jumpers and any other similar items are not to be used for children in care. LPA reminded applicant emergency disaster drills are to be conducted and documented at least once every six months.

Applicant's discipline policy will be redirection and communicating with children's families. The designated isolation area will be with licensee, separate from other children in care. LPA reminded applicant, children must be supervised at all times. Applicant plans to provide a food service that includes breakfast, lunch and snacks. Food preparation, sanitization, children's allergies was discussed.

Applicant's CPR/First Aid training is current and will expire 08/2025. Applicant's Mandated Reporter training certification is also current and will expire 01/2025. LPA reminded applicant CPR/First Aid training and Mandated Reporter training must be renewed every two years. Applicant was also reminded Mandated Reporter training must be renewed every two years by all staff working with children. Applicant has proof of required immunizations (MMR, Tdap and Flu) that were provided to LPA. Per applicant, there are no weapons or firearms in the home.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.
(Continue Report on Page 3...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MENDONCA, MAYRA	FACILITY NUMBER: 384004738
	VISIT DATE: 09/06/2023

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

(Continued, Page 3...)
The applicant provided proof of control of property. The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 children.

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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance checklist was provided to the applicant.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

On this date, 05/18/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.
(Continue Report on Page 4...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MENDONCA, MAYRA	FACILITY NUMBER: 384004738
	VISIT DATE: 09/06/2023

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

(Continued, Page 4...)
Applicant was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

Prior to recommended licensure, following must be completed:
-Posting of all required licensing documentation.
-Fingerprint clearance for all adults living in the home.
-Gate installation on stairs in backyard.
-Child safety lock installation on bathroom cabinet in bathroom #2 (located across nap room).
-Removal of dresser in napping room or securing drawers on dresser in napping room.
-Carbon monoxide detector in nap room and living room.
-Additional padding on fireplace bricks.
-Inaccessibility of guinea pig in living room.

Exit interview conducted and report was reviewed with the applicant, Mayra "May" Mendonca.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4