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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444409060
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:20:11 PM

Document Has Been Signed on 09/23/2022 12:20 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:MENA, MONICAFACILITY NUMBER:
444409060
ADMINISTRATOR:MONICA MENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 348-7110
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 5DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Monica MenaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Licensee, Monica Mena, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee, conducted COVID risk assessment, and toured both indoors and outdoors during the inspection. Upon arrival, there were 5 children (4 preschool-age/ 1 infant) and 2 staff (Licensee & Assistant, David) 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, 6:00AM-6:00PM. Licensee states that she is no longer working with Migrant Head Start.

Licensee states that adults, over the age of 18, residing in the home are: herself and her adult son (David). All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508).

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 reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 7/4/2022, which is compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher (last serviced: 9/2022), functioning smoke detector and carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. The Licensee states that there are no weapons or firearms in the home.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: MENA, MONICA
FACILITY NUMBER: 444409060
VISIT DATE: 09/23/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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: http://www.ada.gov/childqanda.htm

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 inside the home include: laundry room, master bedroom, master bathroom, 2 bedrooms, 1 bathroom, and attached garage. There is a fireplace unit in the home that is properly barricaded, inaccessible to children. The Licensee understands that she cannot use the fireplace unit during day care hours. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Licensee states that when the sun room used for day care gets too warm, she will relocate the children into the living room and kitchen area of the home to stay cool. Drinking water is readily available for children in the facility via water dispensers and cups labeled with the children’s names. The bathroom in the home is operable and equipped with a diaper changing table. LPA advised cleaning the bathroom (toilet) for children's use. The Licensee has a working telephone in the facility. All food (breakfast, lunch, and AM/PM snack) is prepared and provided for children in care through the Community Bridges food program.

The backyard area of the home was inspected and observed to be fenced in. Licensee states that she is currently not utilizing the backyard for children in care and is instead bringing the children to a neighborhood park. LPA advised discontinuing to utilize the backyard until items in disrepair (play structure, canopy beams) are removed for safe use by children. LPA observed sufficient play-equipment and supplies for the children. There is a functioning sink in the backyard that can be used by the children to wash hands as needed. Off-limit areas outside of home include: right side yard, Licensee's sons room (small building located in the play area), and everything beyond the fenced area for children. No outdoor bodies of water were observed during todays inspection. Waivers for water fountain and trampoline are now void as Licensee states that she no longer owns them and LPA did not observe them at the facility.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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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: MENA, MONICA
FACILITY NUMBER: 444409060
VISIT DATE: 09/23/2022
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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.

5 children’s files were reviewed during todays inspection and most required documents were present, including Notification of Additional Child in Care (LIC9150). The Licensee has active liability insurance through KBK Insurance Agency and the policy expires 5/5/2023.

2 staff files (Licensee & Assistant) were reviewed and most required documents were present. There is at least one staff member present with current CPR/First-Aid that expires 4/10/2023 and current Mandated Reporter Training that expires 3/15/2023. 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 transport day care children and LPA confirmed that Licensee has valid CA drivers license (exp: 8/15/2023), vehicle registration, and car seats for transporting children are properly secured in the vehicle (Toyota Highlander). LPA reminded the 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.
Exit interview conducted and report was reviewed with the Licensee, Monica Mena.

As a result of todays inspection, deficiencies were cited, see 809-D.

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

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: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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Document Has Been Signed on 09/23/2022 12:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 09/23/2022 at 11:11 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENA, MONICA
FACILITY NUMBER: 444409060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the children's restroom, as feces were observed in the toilet for children and the backyard, as it is currently in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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Licensee will clean the restroom for children and submit photos of the toilet and sink area. Licensee will additionally clean the backyard of items in disrepair (wooden play structure, wooden beams for canopy, holes in grass, toys in disrepair) and submit photos when she is planning to use again.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 2 out of 5 children in care today, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Licensee will submit updated immunization record for C1 and C2 by 9/28/2022. Licensee should be obtaining updated immunization record for children and LPA advised getting annual update from parents.
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:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/23/2022 12:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 09/23/2022 at 11:11 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MENA, MONICA
FACILITY NUMBER: 444409060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 1 infant in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will maintain documentation of nap checks for and enrolled infants in their file, up to three (3) years. Licensee will submit completed nap checks for C2 on 9/30/2022 for week of nap checks.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


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