434415965-11-29-2022-07-CC-TTRO-CLN3VA-20221129173448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415965
Report Date: 11/29/2022
Date Signed: 11/29/2022 05:34:58 PM

Document Has Been Signed on 11/29/2022 05:34 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	MENDOZA, YURIKO		FACILITY NUMBER:	434415965
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 4	DATE:	11/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Yuriko Mendoza		TIME COMPLETED:	05:45 PM

NARRATIVE

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On 11/29/2022 at 2:03 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Yuriko Mendoza, for an annual inspection and change of capacity visit. Assistant Maria opened the door, LPA explained the reason for the visit to her. Present during today's visit were licensee and assistant Maria with 4 children: two preschool, two infants and one school age child arrived with licensee at 2:20 PM. Adults living in the home are licensee, her spouse and two children ages 3 and 6. Days and hours of operation are Monday through Friday 5:00 AM to 6:000 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 11/16/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA inspected inside and outside of two story home. LPA observed a barricaded fireplace, no wall heater, no barricaded stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have a dog and they are vaccinated. LPA observed a fully charged 2A10BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on top kitchen cabinet. Front yard is fenced. Off limit areas: all upstairs, a storage room by kitchen, garage, left side barricaded yard.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 8 children according to their license. Licensee stated they do transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues on report dated 11/29/2022 pg. 1/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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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Document Has Been Signed on 11/29/2022 05:34 PM - It Cannot Be Edited

Created By: Teodoro Trujillo On 11/29/2022 at 04:34 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, YURIKO	FACILITY NUMBER: 434415965
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(3)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in stairs were not barricaded during inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2022
	Plan of Correction
1 2 3 4	Licensee immediately installed a gate to stairs.

Type B

Section Cited

CCR

102417(g)(4)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, clothes detergent was accessible on top of washing machine, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2022
	Plan of Correction
1 2 3 4	Licensee immediately moved the detergent to upper cabinet in laundry room closet, inaccessible to children in care.

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:

Mary Segura

LICENSING EVALUATOR NAME:

Teodoro Trujillo

LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENDOZA, YURIKO	FACILITY NUMBER: 434415965
	VISIT DATE: 11/29/2022

NARRATIVE

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Continuation of report dated 11/29/2022 pg. 2/3
LPA reviewed current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 11/01/22. LPA reviewed 5 children’s files and observed all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has Mandated Reporter training, training was completed on 07/21/2022 and assistant Maria completed 7/11/2022. Licensee has Pediatric CPR/1^st Aid expiring 7/26/2024 and assistant completed with an American BLS expiring on 06/01/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care. PIN 22-02-CCP was provided.

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-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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENDOZA, YURIKO	FACILITY NUMBER: 434415965
	VISIT DATE: 11/29/2022

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Licensee did not provide LIC 9151 Property Owner/Landlord Notification Family Child Care Home. License will be pending for change of capacity pending Licensing Program Manager apporoval.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed in Spanish with the licensee, Yuriko Mendoza. 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: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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