Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014871
Report Date: 04/15/2016
Date Signed: 04/15/2016 10:18:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:MAYORGA FAMILY CHILD CAREFACILITY NUMBER:
198014871
ADMINISTRATOR:MAYORGA, INESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 305-2548
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:14CENSUS: 7DATE:
04/15/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ines & Marcelo MayorgaTIME COMPLETED:
10:20 AM
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This is an unannounced random visit conducted today by LPAs Jennifer Hua & Seung Lee. LPAs met with licensee and her spouse who guided analyst on a tour of the facility. All areas identified on the facility sketch were inspected. This is a two story home. Family members residing at facility are 2 adults, licensee, Ines and spouse Marcelo Mayorga and no children. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Downstairs, licensee converted the Dining Room and Family Room to create a children's play / activity room for day care children. (day care room). restroom in day are room is use for children.

Backyard is adequately fenced and there is no * swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and napping equipment on the premises.

- The required fire extinguisher (2A 10BC) and smoke/carbon monoxide detectors are in operable condition.Fire extinguisher is fully charged and was purchased on 11/23/15.
- Per licensee, there are no weapons, firearms in the facility at this time.

Licensee is current in Pediatric CPR/FIrst Aid. Certificate expires on 4/25/17.

Areas off limits include: all of upstairs: Four bedrooms, two complete restrooms, Downstairs: Living Room, half restroom, garage(only to be used when parents drop off/pick up child(ren). kitchen.


Report continues on the next page.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2016
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MAYORGA FAMILY CHILD CARE
FACILITY NUMBER: 198014871
VISIT DATE: 04/15/2016
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Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby, Last drills conducted on 10/2016.

· Dog(s) and or pets should be isolated from children in care.
· It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

Per Licensee, Incidental Medical Services is not provided at this time.

Notice of Site Visit Form was provided and explained. The notice must be posted in a prominent area for 30 days or a civil penalty of $100 will be assessed.

No deficiency cited during this visit.


- Exit interview was conducted with licensee. NOTICE OF SITE VISIT PROVIDED AND EXPLAINED. Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2016
LIC809 (FAS) - (06/04)
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