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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421887
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:16:45 PM

Document Has Been Signed on 05/21/2024 03:16 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CORDOVA, MERCEDESFACILITY NUMBER:
013421887
ADMINISTRATOR/
DIRECTOR:		CORDOVA, MERCEDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 677-5500
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
05/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Mercedes Cordova/ Mercedes CordovaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 05/21/2024 at 11:45 AM Licensing Program Analyst (LPA), A. Curry arrived at the home and conducted an unannounced annual/random inspection. LPA met with licensee, Mercedes Cordova, who granted inspection authority to tour the facility. Also present for the inspection were licensee’s 2 fingerprint cleared assistants and 11 children in care, consisting of 2 infants and 9 preschoolers. Licensee states there are currently 12 children enrolled. Children and staff files were reviewed. 1 staff did not have required immunization record in file (See 809D).


The entrance to the day care is located on the left side of the home. The children use the front room, bathroom in the hallway, bedroom #1 located next to the bathroom, nook, living room, outside patio located next to the living room, and the side yard. The off-limits areas will be inaccessible by closed and/or locked doors and visual supervision. The isolation area is in the nook. The LPA toured all areas used by children.

Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There were safe toys, play equipment, and materials observed for children. There is a gate at the bottom of the stairs . There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 2A10BC fire extinguisher and working dual smoke alarm/ carbon monoxide detector. Licensee stated there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on November 09, 2025.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CORDOVA, MERCEDES
FACILITY NUMBER: 013421887
VISIT DATE: 05/21/2024
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LPA observed and inspected sleeping equipment for infants. All equipment meets the US Consumer Product Safety Commission standards. LPA observed that cribs and/or play yards were free from loose articles and objects. There are no objects hanging above or attached to the side of the crib. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was reminded that all infants up to 12 months of age shall have the LIC 9227 form placed in their file.

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-and-resources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. PIN 22-05-CCP

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.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CORDOVA, MERCEDES
FACILITY NUMBER: 013421887
VISIT DATE: 05/21/2024
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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, Mercedes Cordova, 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, appeal rights were given, and report was reviewed with the licensee's daughter, Mercedes Cordova.











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.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2024 03:16 PM - It Cannot Be Edited


Created By: Ashley Curry On 05/21/2024 at 12:44 PM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CORDOVA, MERCEDES
FACILITY NUMBER: 013421887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by ensuring all staff/volunteers have required immunization records in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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By 06/21/2024 email LPA proof of immunity to Measles, Pertussis, and T.B for Janet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


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