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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004938
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:23:54 AM

Document Has Been Signed on 05/09/2023 11:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MENDEZ, ANA FAMILY CHILD CARE HOMEFACILITY NUMBER:
493004938
ADMINISTRATOR:MENDEZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 795-1202
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
05/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Quetzali HernandezTIME COMPLETED:
11:33 AM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother made an unannounced case management inspection to the facility while attending to other matters in the facility. During today's inspection, LPA met with Licensee's assistant, Quetzali Hernandez, Staff 1 (S1). During today's inspection, LPA requested to review safe sleep logs dated 12/15/22. The licensee did not have safe sleep logs, specific to 12/15/22 available for LPA to review. S1 informed LPA that they do not have sleep logs to provide and were not aware of the safe sleep regulations at the time, 12/15/22. LPA provided technical assistance reviewing the infant safe sleep regulations, form LIC9227 for infants under 12 months and a sample sleep log for children 0 months to 2 years old.

The following violations of the California Code of Regulations, Title 22; Division 12 were observed during today's inspection. See LIC 809-D for deficiency cited during today's inspection.

This report was reviewed and discussed with facility representative, Quetzali Hernandez. Appeal Rights were provided.

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: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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 05/09/2023 11:23 AM - It Cannot Be Edited


Created By: Amy Strother On 05/09/2023 at 08:58 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MENDEZ, ANA FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited
CCR
102425(j)(2)(A)

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102425(j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1)The provider shall physically check on the infant every 15 minutes. (2)The provider shall check and document the following:(A)Labored breathing.

This requirement was not met as evidenced by:
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Licensee will write out a procedure detailing what must be included on a safe sleep log and how the Licensee will follow the procedure.
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Based on interview and record review, the Licensee did not keep a safe sleep log on
12/15/22, which poses a potential Health and Safety risk to children in care.
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Written procedure will be sent to LPA Leticia Rosales's email: leticia.rosales@dss.ca.gov

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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