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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415622
Report Date: 04/01/2022
Date Signed: 04/01/2022 11:44:05 AM

Document Has Been Signed on 04/01/2022 11:44 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MENDOZA MENDEZ, MAYRAFACILITY NUMBER:
434415622
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 0DATE:
04/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mayra Mendoza MendezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Mayra Mendoza Mendez and explained the reason for the visit. Present were licensee and licensee's 17 year old son. Licensee did not open her day care today.

LPA reviewed and obtained photos of children's roster and sign-in and out sheets. Licensing states she let some children go so she could be in compliance with regulations. LPA observed the home is in Title 22 compliance.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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