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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515407999
Report Date: 02/05/2024
Date Signed: 02/05/2024 12:04:07 PM

Document Has Been Signed on 02/05/2024 12:04 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MENJIVAR, BELEN AND MARTINEZ MENJIVAR, JOSE FCCHFACILITY NUMBER:
515407999
ADMINISTRATOR:BELEN, MENJIVAR AND JOSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 441-6121
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
02/05/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jose Martinez MenjivarTIME COMPLETED:
12:13 PM
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On 2/5/2024 at 10:00am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), T.Dutra and S.Sims. At 10:25am the home was toured inside and outside. The licensee was supervising 1 child and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5pm-5am, Monday–Sunday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are master bedroom and the garage, and were made inaccessible by top latch locks. The children use the back yard as the outdoor play area and it is fully fenced. There were no pools or other bodies of water observed in the yard.

No children's files were available for review. No staff records were available for review. There are currently two adults living in the home.

The following deficiencies were cited upon inspection, mandated reporter certificate expired for one Licensee and no children's files available for review. Licensees.(see LIC 809D):


SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MENJIVAR, BELEN AND MARTINEZ MENJIVAR, JOSE FCCH
FACILITY NUMBER: 515407999
VISIT DATE: 02/05/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/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.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MENJIVAR, BELEN AND MARTINEZ MENJIVAR, JOSE FCCH
FACILITY NUMBER: 515407999
VISIT DATE: 02/05/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Jose Menjivar Martinez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Jose Menjivar Martinez.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2024 12:04 PM - It Cannot Be Edited


Created By: Tammy Dutra On 02/05/2024 at 11:27 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: MENJIVAR, BELEN AND MARTINEZ MENJIVAR, JOSE FCCH
FACILITY NUMBER: 515407999

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in expired mandated reporter for Licensee, Jose which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee, Jose to complete mandated reporter training by 2/16/2024 and submit to CCLD. Return certificate to LPA @ tammy.dutra@dss.ca.gov.
Type B
Section Cited
CCR
102391(d)
Inspection Authority of the Department
(d) The licensee shall permit the Department to inspect, audit, and copy children's records or other family child care home records upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in there were no childrens files to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee to submit a child's file to CCLD by 2/16/2024. Licensee to email LPA @ tammy.dutra@dss.ca.gov.
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:Erin Virrueta
LICENSING EVALUATOR NAME:Tammy Dutra
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024


LIC809 (FAS) - (06/04)
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