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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515402910
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:09:11 PM

Document Has Been Signed on 08/03/2022 12:09 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MENDOZA, JOSEFINA FAMILY CHILD CARE HOMEFACILITY NUMBER:
515402910
ADMINISTRATOR:MENDOZA, JOSEFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 870-8297
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Josefina MendozaTIME COMPLETED:
12:10 PM
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On 8/3/2022, at 9:50am a Required -1 Year inspection was made to the facility by Licensing Program Analyst (LPA), Laura Chavez. At 10:10am the home was toured inside and outside. The licensee was supervising 8 children and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 7:00am-5:30pm, Monday–Friday. A review of the Facility Personnel Report Summary dated 7/26/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. The floor plan and yard sketch submitted by the licensee were reviewed and verified. The off-limits areas of the home are the main portion of the first floor and entire second floor of the home. Child care is provided in the large play room. A gate at the bottom of the stairs prevent children from accessing the second floor. The children use half of of the back yard as the outdoor play area and it is fully fenced. The backyard is divided in half by means of a chain link fence. There were no pools or other bodies of water observed in the yard.

Items that could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) are stored out of the reach of children. Poisons are locked in a shed located in the backyard. The LPA observed a working smoke detector, carbon monoxide detector, and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. Report continued: See LIC 809-C's
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MENDOZA, JOSEFINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515402910
VISIT DATE: 08/03/2022
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The licensee stated that an emergency drill was conducted within the past six months. Eight children's records were reviewed at 10:30am. One staff record was reviewed at 11:00am. There are currently three adults living in the home. The 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 discussed the safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep web page at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-
resources/safe-sleep as an additional resource. LPA also informed the 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.

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 (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Report continued
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MENDOZA, JOSEFINA FAMILY CHILD CARE HOME
FACILITY NUMBER: 515402910
VISIT DATE: 08/03/2022
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There were no deficiencies cited during today’s inspection.

An exit interview was conducted, and the report was reviewed with licensee Josefina Mendoza.



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.

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: Megan Aviles
LICENSING EVALUATOR NAME: Laura Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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