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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444409060
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:49:35 AM

Document Has Been Signed on 02/17/2022 10:49 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:MENA, MONICAFACILITY NUMBER:
444409060
ADMINISTRATOR:MONICA MENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 348-7110
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Monica MenaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs), Cortney Nelson and Janette Cruz, met with Licensee, Monica Mena, for case management inspection. Case Management has been initiated regarding staff qualifications for Licensee's nephew, Juan Antonio Munoz.

On 2/3/2022 LPA Nelson received phone call from Licensee regarding fingerprint clearances for her nephew, Juan. It was discovered that Juan had previously been fingerprinted on 6/3/2019, however the facility number was incorrectly entered, resulting in his fingerprints not being associated to the facility.

LPA Nelson reached out to Guardian to associate Juan's fingerprints to the facility and he was fully associated to the facility on 2/3/2022.

LPA Nelson arrived to Licensee's Family Child Care Home (FCCH), to review Juan's staff file for all necessary components as Monica states that he transports children for her when she has more children due to the Migrant Head Start program. LPA Nelson inquired when was the last time Juan transported children and she states that it was on November 8-17, 2021.

LPA Nelson observed Juan's Mandated Reporter training is current and expires on 10/16/2022. Juan's First-Aid/CPR is expired as of 8/1/2021. Juan has current TB test and immunization record on file.

As per Licensee statement, the last time Juan transported children was on 11/8/2021 and his CPR/First-Aid expired on 8/1/2021 and due to this, deficiency has been cited. See 809-D.

Exit interview was conducted with Licensee, Monica Mena, and appeal rights were provided.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 02/17/2022 10:49 AM - It Cannot Be Edited


Created By: Cortney Nelson On 02/17/2022 at 10:04 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
CCR
102416(c)

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102416 Personnel Requirements (c) The licensee and other personnel... shall complete training... including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
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Licensee will submit current CPR/First-Aid for staff by 3/17/2022 if staff will continue to transport children. If Licensee no longer needs staff's assistance, Licensee will submit statement indicating that staff will no longer assist with transportation of children and the effective date.
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Based on observation, record review, and interviews, the Licensee did not have current CPR/First-Aid for her staff that provided transportation for children in care.
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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: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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