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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192005786
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:31:21 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/05/2022 12:31 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MENDOZA FAMILY CHILD CAREFACILITY NUMBER:
192005786
ADMINISTRATOR:MENDOZA, NORMA I.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 564-6475
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Norma Mendoza, LicenseeTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a Case Management inspection. Licensee, Norma, was present. Per licensee, there are no children currently enrolled. No children were observed on this date. Licensee provided tour of home, including off limit areas. All All adults present have been fingerprint cleared. Individuals residing in the home were discussed and noted.

Licensee’s fees are currently overdue per LIS database inquiry by LPA. LPA provided licensee with the information needed to pay fees .
The Licensee requested inactive status due to family and personal needs. Licensee completed LIC 9211 Request for Inactive Status. LPA discussed with licensee the requirement to follow the condition during the inactive status period.

Exit interview conducted with Licensee, Norma Mendoza. A copy of this report was provided.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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