Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014871
Report Date: 08/03/2017
Date Signed: 08/03/2017 01:41:01 PM

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: 11DATE:
08/03/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Ines Mayorga & Marcelo MayorgaTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This is an unannounced random inspection conducted today by LPAs Jennifer Hua. LPA 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 care 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 11/27/16.
- Per licensee, there are no weapons, firearms in the facility at this time.

Licensee is current in Pediatric CPR/FIrst Aid. Certificate expires on 5/13/19.

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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 08/03/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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, A Child Care Provider's Guide to Safe Sleep was provided to licensee. Drills conducted on 5/15/17. .

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) 514-0388 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm Per Licensee, IMS is not provided.


· 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.

Deficiencies cited on attached 809D..


Exit interview was conducted with licensee. Appeal Rights procedures explained and provided.
Site visit notice posted. And Licensee advised to keep notice posted for 30 days.
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3


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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2017
Section Cited
H&S1596.7995(c)
1
2
3
4
5
6
7
Immunization Requirements. Effective 9/1/16, all individuals who provide care and supervision to children are required to obtain immunizations for Pertussis, Measles and Influenza. LPA observed licensee and her spouse do not have record of vaccines.
1
2
3
4
5
6
7
Per licensee, will correct and submit copies to Licensing
Type B
08/07/2017
Section Cited
102418(g)(1)
1
2
3
4
5
6
7
Immunizations. The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. LPA observed 1file lack record and 2 needs updates
1
2
3
4
5
6
7
Per licensee, will correct and submit copies to Licensing.
Type B
08/07/2017
Section Cited
102417(g)(7)
1
2
3
4
5
6
7
Operation of a Family Child Care Home.The licensee shall maintain the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. LPA observed 1 file lack form.
1
2
3
4
5
6
7
Per licensee, will correct and submit copy to Licensing.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3