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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406780
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:27:04 PM

Document Has Been Signed on 12/12/2024 04:27 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MENDOZA, SANDRAFACILITY NUMBER:
434406780
ADMINISTRATOR/
DIRECTOR:		MENDOZA, SANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 979-0148
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
12/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Sandra Mendoza, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Licensee, Sandra Mendoza, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 8 children (6 preschool aged and 2 infant aged) and 3 staff (Licensee and 2 helpers) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 07:30AM-05:30PM. There are no active waivers.

Licensee states that adults, over the age of 18, residing in the home are: herself, her spouse (Ramon) and her son (Jose). All adults residing in the home have Criminal Background Check Clearance. 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. All staff present had criminal background check clearance.

LPA reviewed facility roster (LIC9040) and fire/disaster drill log during today's inspection. The last fire/disaster drill was conducted on 11/08/2024, which is compliant with the six month requirement for homes. LPA observed a fully charged 2A10BC fire extinguisher that was last serviced 10/01/2024 which is compliant with state fire marshal regulations. LPA observed a functioning smoke detector and carbon monoxide detector. Licensee carries liability insurance the policy is effective from 11/20/2024-11/20/2025.

Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 12/12/2024 04:27 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 12/12/2024 at 03:30 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENDOZA, SANDRA
FACILITY NUMBER: 434406780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section by not having the flu vaccination/declination on file for 3 out of 3 staff and missing immunization records for 2 out of 3 staff files. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee to locate missing documentation and provide photographic evidence to LPA.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 children's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee to complete LIC9227 for all children in care that were enrolled prior to their 1st birthday and send photographic evidence to the LPA.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


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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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MENDOZA, SANDRA
FACILITY NUMBER: 434406780
VISIT DATE: 12/12/2024
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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/.

Licensee states there are no firearms or weapons stored in the household.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): 3 bedrooms and garage. There are no open-faced heaters in the home or fireplaces. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via water dispenser in the day care room with reusable cups with children's names. The bathrooms in the home are clean, sanitary, and operable. The Licensee uses her cell phone to communicate with parents (408-425-2906).

The backyard area of the home was inspected. LPA observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. There was rubber resilient material throughout the whole backyard. Off-limit areas outside of home include: both side yard areas and the front yard. No outdoor bodies of water were observed during today's inspection.

Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age need to have the LIC9227 filled out completely and the document should be kept in the child's file as long as they are in care with provider. LPA also reminded the licensee that infants 12 months old or younger should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MENDOZA, SANDRA
FACILITY NUMBER: 434406780
VISIT DATE: 12/12/2024
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LPA reminded licensee to refer to the resource provided below if she had further questions regarding safe sleep. Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee 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.

4 children’s files were reviewed during today's inspection including Individual Infant Sleep Plan (LIC9227) and sleep check documentation for all infants, Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Immunization Records (PM286). LPA found all files to be filled out incorrect LIC9227 or the document was missing completely. LPA discussed with licensee how to properly fill out forms and created a plan of correction to resubmit the LIC9227 to the department.

3 staff files (1 licensee and 2 helpers) were reviewed. Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza or statement declining influenza. LPA observed 2 out of 3 files missing immunization records and 3 out of 3 files did not have a flu vaccination or declination. There is at least one staff member present with current CPR/First-Aid that expires 08/20/2026. The Licensee has current Mandated Reporter Training that expires on 11/23/2025 and LPA reminded licensee that training must be renewed by all staff every 2 years.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MENDOZA, SANDRA
FACILITY NUMBER: 434406780
VISIT DATE: 12/12/2024
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Licensee 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.

Due to today's inspection 2 Type B deficiencies were cited. More details provided in the attached LIC809-D. Exit interview conducted with licensee, Sandra Mendoza, report reviewed and provided to licensee along with appeal rights.

NOTICE OF SITE VISIT WAS PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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